Benign prostatic hyperplasia with lower urinary tract symp

This code represents an enlarged prostate gland (benign prostatic hyperplasia) that is causing bothersome urinary symptoms. These symptoms, collectively known as lower urinary tract symptoms (LUTS), can include increased urinary frequency, urgency, nocturia, weak stream, or incomplete bladder emptying.

Use this code when documentation clearly indicates a diagnosis of benign prostatic hyperplasia (BPH) and specifically mentions associated lower urinary tract symptoms. This is appropriate for patients presenting with or being treated for urinary issues directly attributable to their enlarged prostate.

• Ensure the physician's documentation explicitly links the LUTS to BPH; simply having BPH and LUTS separately is not sufficient.
• Do not use this code if the BPH is without LUTS (N40.0) or if there is prostatic enlargement of unspecified type (N40.8 or N40.9).
• Consider sequencing if other conditions are also being treated; BPH with LUTS may be a primary or secondary diagnosis depending on the encounter's focus.