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600.91 and 600.01

Nancy Posted Thu 28th of May, 2015 12:38:07 PM

I need some help and an opinion with ICD-9 code 600.91 and 600.01. So if the physician states in note patient coming in for his hyperplasia 600.91 or 600.90 with and without obstruction but codes it as 600.01 benign prostate hypertrophy, my question is what is the difference?
1. Hyperplasia - the enlargement of an organ or tissue caused by an increase in the reproduction rate of its cells, often as an initial stage in the development of cancer.
1. Hypertrophy - the enlargement of an organ or tissue from the increase in size of its cells.
I
The only difference I see is the increase reproduction rate of cells versus increase in size of cells. I want to make sure notes are being coded correctly.
Example of my dilemma:

This is a 65-year-old gentleman presents to the office for follow-up of benign prostatic hyperplasia. He takes Jalyn one pill daily with good results. He denies side effects. His only health complaint is that of mild fatigue in the afternoon. Otherwise, he feels well and denies any update to his past medical history. His AUA symptom index is well controlled on this medication.

IMPRESSION:
1) BENIGN PROSTATIC HYPERTROPHY; WITH URINARY OBSTRUCTION.
2) PSA; INCREASED.
Should I use 600.01 or 600.91? Stating hyperplasia in note but uses 600.01 benign hypertrophy as Dx code.

SuperCoder Answered Fri 29th of May, 2015 01:51:59 AM

BPH stands for both Benign Prostate Hypertrophy and Benign Prostate Hyperplasia. You must query the provider that diagnosis should be more specified that whether it is hypertrophy or hyperplasia, to avoid any future mistakes.
The most preferred code is 600.01.

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