Nodular prostate with lower urinary tract symptoms

This code signifies benign prostatic hyperplasia (BPH) characterized by palpable nodules on the prostate gland, accompanied by bothersome lower urinary tract symptoms (LUTS). These symptoms often include urinary frequency, urgency, nocturia, weak stream, or incomplete bladder emptying. It represents a symptomatic, nodular enlargement of the prostate.

Apply this code when documentation explicitly states "nodular prostate" or "nodular BPH" in conjunction with specific LUTS. This diagnosis is typically supported by physical examination findings (e.g., DRE revealing an enlarged, nodular prostate) and patient-reported symptoms. It is appropriate when the physician links the LUTS directly to the nodular prostatic enlargement.

• Ensure documentation clearly links the LUTS to the nodular prostate; avoid coding LUTS separately if they are a manifestation of the BPH.
• Do not use this code if the prostate enlargement is described as diffuse without specific mention of nodularity.
• Consider sequencing this code as the primary diagnosis when it is the main reason for the encounter and treatment.