Benign Prostatic Hyperplasia (BPH) ICD-10-CM codes

Category N40 has four codes. N40.0 is BPH without lower urinary tract symptoms and N40.1 is BPH with lower urinary tract symptoms (LUTS). Nodular prostate is separated into N40.2 (without LUTS) and N40.3 (with LUTS). An enlarged prostate documented with no mention of symptoms defaults to N40.0; assign N40.1 only when the provider links urinary symptoms to the BPH.

N40.1 and N40.3 carry a use-additional-code note for the symptoms present, so report them with the specific symptom codes: R35.0 frequency, R35.1 nocturia, R39.11 hesitancy, R39.12 poor stream, R39.14 incomplete emptying, R39.15 urgency, R39.16 straining, R33.8 other urinary retention, and N13.8 for obstructive uropathy. Listing the symptoms is what distinguishes N40.1 from N40.0 on audit; do not report N40.1 with no symptom codes attached.

An elevated PSA found during BPH workup is R97.20 and may be reported with N40.-. Prostatitis is category N41 and prostate cancer is C61; neither is coded as BPH. Acute urinary retention due to BPH is N40.1 plus R33.8.