ICD Code N40.0

ICD code N40.0 is used to classify a diagnosis of benign prostatic hyperplasia (BPH) without any associated lower urinary tract symptoms. This means that the patient has an enlarged prostate gland, which is common in older men, but they are not experiencing symptoms such as difficulty urinating, increased frequency, or urgency. This code is important for healthcare providers to accurately document and manage the condition for treatment and billing purposes.

1. Prostate Enlargement: The patient must have an enlarged prostate, which can be confirmed through a physical examination or imaging studies such as an ultrasound.

2. Absence of Lower Urinary Tract Symptoms (LUTS): The patient should not exhibit any lower urinary tract symptoms, which typically include:

• Frequent urination
• Urgency to urinate
• Nocturia (waking up at night to urinate)
• Weak urine stream
• Difficulty starting urination
• Dribbling at the end of urination

3. Normal Urinalysis: A urinalysis should not show any abnormalities that could indicate infection or other urinary conditions.

4. Normal Post-Void Residual Volume: The amount of urine left in the bladder after urination should be within normal limits, indicating that the bladder is emptying properly.

5. No Evidence of Urinary Tract Infection (UTI): The patient should not have any signs or symptoms of a urinary tract infection, which could include pain during urination, cloudy urine, or a strong urge to urinate.

6. No History of Urinary Retention: The patient should not have a history of acute or chronic urinary retention, which is the inability to empty the bladder completely.

7. No Hematuria: There should be no presence of blood in the urine, which could suggest other underlying conditions.

8. No Bladder Stones or Tumors: Diagnostic imaging should rule out the presence of bladder stones or tumors that could cause similar symptoms.

9. Normal Prostate-Specific Antigen (PSA) Levels: PSA levels should be within normal range, as elevated levels could indicate other prostate conditions.

10. No Neurological Disorders Affecting Urination: The patient should not have any neurological disorders that could affect bladder function, such as multiple sclerosis or spinal cord injuries.

For the ICD code N40.0, which pertains to benign prostatic hyperplasia without lower urinary tract symptoms, the relevant CPT codes that may be applicable include:

1. CPT 52601 - Transurethral electrosurgical resection of the prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included).

2. CPT 52648 - Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed).

3. CPT 52649 - Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed).

4. CPT 55866 - Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed.

5. CPT 55831 - Prostatectomy, suprapubic, subtotal resection of prostate, including control of postoperative bleeding, complete.

These CPT codes are commonly associated with procedures that may be performed for conditions related to benign prostatic hyperplasia, although the specific choice of procedure will depend on the individual patient's clinical situation and the healthcare provider's judgment.

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