Pathology/Lab Coding Alert

Question: The pathologist examines a prostate biopsy and diagnoses “benign prostatic hypertrophy (BPH).” The referring urologist ordered the biopsy due to urinary hesitancy and retention. What diagnosis codes should we use under ICD-10?

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Answer: The correct code is N40.1 (Enlarged prostate with lower urinary tract symptoms). Because instruction under N40.1 tells you to “use additional code for associated symptoms, when specified,” you should also report the urinary tract symptoms identified by the ordering physician: R39.11 (Hesitancy of micturition) and R33.8 (Other retention of urine).

Pathology coders may have trouble finding the ICD-10 code for BPH, because the new code set doesn’t use that terminology, as ICD-9 did. Instead, ICD-10 uses the more general term “enlarged prostate” that includes BPH. You should distinguish the ICD-10 enlarged prostate codes based on the presence or absence of urinary symptoms.