Wiki Not sure if BPH dx is supported

[tag60]

A male patient, new to clinic, comes in with nocturia and complaint of weaker, slower stream. No prior dx of BPH. Provider's exam only states well-nourished, well-developed male" and does NOT include a rectal.

Diagnosis: "Nocturia associated with benign prostatic hypertrophy (finding) 600.01."

Plan: Send for UA and PSA. Start Cardura at bedtime.

Addendum: PSA is up. UA had blood. Needs urology referral.

Would I code the nocturia (788.43) or the BPH with LUTS (600.01)? I question because there is no exam to confirm enlarged prostate and no prior history of BPH. I know these are symptoms of BPH, but could they as well be symptoms of another condition and we can't assume BPH unless exam or further testing confirms? Or is the provider's assessment enough? (I also question because my providers often give dx of what they suspect rather than what is confirmed via exam or tests. However, in this note he does not state "suspect" BPH but gives it as the diagnosis.)

Thank you for your help!

 

[kjenkinstx21@gmail.com]

I would code 600.01 and 788.43 per the instructions in icd-9. The physics probably determined that patient has an enlarged prostate by doing a digital rectal exam. Hope this helps.

 

[tag60]

Well, that's just it -- as I stated, there is no exam done, so I'm wondering if the provider's diagnosis based on symptoms is enough to establish an enlarged prostate.

 

[mitchellde]

We do not question the providers diagnosis as long as it is stated in the providers note and not just checked on a superbill or encounter slip. So if he states BPH in the note then that is what you code.