Benign Prostatic Hyperplasia (BPH) Documentation Guide
Non-malignant enlargement of the prostate gland causing lower urinary tract symptoms in men.
ICD-10 Codes: N40.0, N40.1
Common Symptoms
- Urinary frequency
- Nocturia
- Weak urinary stream
- Hesitancy
- Incomplete emptying
Key Documentation Elements
- IPSS or AUA symptom score
- Digital rectal exam findings
- PSA level and trend
- Post-void residual volume
- Current pharmacotherapy (alpha-blockers, 5-ARIs)
Documentation Challenges
- Quantifying symptom severity with validated instruments
- Documenting IPSS/AUA symptom score changes
- Recording post-void residual and uroflow results
- Capturing medication trial history and response
Billing Considerations
- N40.0 (without LUTS) vs N40.1 (with LUTS) distinction
- Procedure coding for cystoscopy or TURP if performed
- PSA screening documentation and coding
Frequently Asked Questions
What is the difference between N40.0 and N40.1?
N40.0 is BPH without lower urinary tract symptoms, while N40.1 is BPH with LUTS. Most clinical encounters involve N40.1. Scribeable selects the appropriate code based on your documented symptom assessment.
How does Scribeable help with BPH documentation?
Scribeable captures IPSS scores, exam findings, PSA trends, and medication management from your encounter, creating well-structured urology notes that support treatment decisions and proper coding.