Don't have a TCI SuperCoder account yet? Become a Member >>

Regular Price: $24.95

Ask An Expert Starting at $24.95
Have a medical coding or compliance question? Don’t sacrifice your valuable time to endless research. Choose Ask an Expert to get clear answers from the TCI SuperCoder team. And here’s a tip for the budget-conscious: Select the 12-question pack to get the best rate per question!

Browse Past Questions By Specialty

+View all

LUTS for BPH

David Posted Mon 12th of October, 2015 11:30:27 AM

I work for a urology practice and the previous coders allowed the physicians to state in the notes that a patients has LUTS, and they would code BPH w/LUTS ICD-9 600.01.
I see in the medical dictionary that LUTS is a modern day term for prostatism with is also considered BPH.
My question is, stating a patient has LUTS, really the same as stating a patient has BPH with LUTS? To me LUTS is referring to lower urinary tract symptoms which anyone could have. But we can not seem to get our doctors out of this habit of just stating LUTS, which leads us to code the actual symptoms the patient is having instead of BPH.

Are we being to picky or should we stick to this and require the physician to state the patient has BPH? Wondering which is right.

SuperCoder Answered Tue 13th of October, 2015 08:25:42 AM

Both you and your provider is correct. Now a days, ICD-9 600.01 is being used for Prostatism as well as for LUTS. Please find below the article on it.

AHA ICD-9-CM Coding Clinic
New/Revised Codes: Prostate Hypertrophy and Lower Urinary Tract Symptoms (2006 Vol.23 No.4)
Effective October 1, 2006, changes have been made to hyperplasia of prostate categories 600.0, 600.2 and 600.9 to include in the code titles "and other lower urinary tract symptoms." This allows the use of these codes when there is prostatic hyperplasia with lower urinary tract symptoms such as incomplete bladder emptying, nocturia, straining on urination, urinary frequency, urinary hesitancy, urinary incontinence, urinary retention, urinary urgency and weak urinary stream. In addition, separate codes may be reported to identify these symptoms.

600 Hyperplasia of prostate

Add Includes: enlarged prostate

Delete Use additional code to identify urinary incontinence (788.30-788.39)

600.0 Hypertrophy (benign) of prostate

Revise 600.00 Hypertrophy (benign) of prostate without
urinary obstruction and other lower urinary
tract symptoms (LUTS)

Revise 600.01 Hypertrophy (benign) of prostate with urinary
obstruction and other lower urinary tract
symptoms (LUTS)

Add Use additional code to identify symptoms:
incomplete bladder emptying (788.21)
nocturia (788.43)
straining on urination (788.65)
urinary frequency (788.41)
urinary hesitancy (788.64)
urinary incontinence (788.30-788.39)
urinary obstruction (599.69)
urinary retention (788.20)
urinary urgency (788.63)
weak urinary stream (788.62)

600.2 Benign localized hyperplasia of prostate

Revise 600.20 Benign localized hyperplasia of prostate without
urinary obstruction and other lower urinary tract symptoms (LUTS)

Revise 600.21 Benign localized hyperplasia of prostate with
urinary obstruction and other lower urinary
tract symptoms (LUTS)

Add Use additional code to identify symptoms:
incomplete bladder emptying (788.21)
nocturia (788.43)
straining on urination (788.65)
urinary frequency (788.41)
urinary hesitancy (788.64)
urinary incontinence (788.30-788.39)
urinary obstruction (599.69)
urinary retention (788.20)
urinary urgency (788.63)
weak urinary stream (788.62)

600.9 Hyperplasia of prostate, unspecified

Revise 600.90 Hyperplasia of prostate, unspecified, without
urinary obstruction and other lower urinary
symptoms (LUTS)

Revise 600.91 Hyperplasia of prostate, unspecified, with
urinary obstruction and other lower urinary
symptoms (LUTS)

Add Use additional code to identify symptoms:
incomplete bladder emptying (788.21)
nocturia (788.43)
straining on urination (788.65)
urinary frequency (788.41)
urinary hesitancy (788.64)
urinary incontinence (788.30-788.39)
urinary obstruction (599.69)
urinary retention (788.20)
urinary urgency (788.63)
weak urinary stream (788.62)

Question:
A male patient is seen and treated for benign prostatic hypertrophy (BPH) and urinary retention. How should this be coded?

Answer:
Assign code 600.01, Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS), followed by code 788.20, Retention of urine, unspecified, for the diagnosis of BPH and urinary retention.

Also, find the link below: https://www.supercoder.com/icd_coding_clinic/codingclinic_icd_details/508

David Posted Tue 13th of October, 2015 10:36:12 AM

I do understand that if the patient has BPH w/LUTS that we code BPH and the associated symptoms that go along with it.

My concern is if the notes simply state the patient has LUTS, with no mention of BPH. If the provider does not mention BPH in his notes....should we just code the symptoms (LUTS - lower urinary tract symptoms)?

Or since our providers by stating a patient has LUTS are implying that the patient has BPH w/LUTS....can we code it has such, listing the symptoms? Will this be justified in an audit?

SuperCoder Answered Wed 14th of October, 2015 09:03:03 AM

Yes, for one particular ICD, physician may use multiple terminology as happened in your case. Hence, for hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract ICD-9 600.01 can be use, where LUTS is subsitute for BPH.

Thank you

Related Topics