Enlargement of the prostate gland, also known as benign prostatic hyperplasia or hypertrophy (BPH), is a simple and unfortunate consequence of aging. BPH affects most men over the age of 60, and is so common that it has been said that all men will have an enlarged prostate if they live long enough. Every year, approximately 2 million men in the U.S. are treated for BPH and 400,000 have some kind of surgical procedure.
This column will cover the coding guidelines related to BPH and transurethral procedures that are most often performed to alleviate severe signs and symptoms associated with this condition.
BPH is a nonmalignant enlargement of the prostate gland due to a slow continuous growth. The growth occurs over the years, and usually does not cause a problem until the outer layer of the gland stops expanding, causing the tissue to press inward and constrict the urethra. Though the prostate continues to grow during most of a man's life, the enlargement doesn't usually cause problems until late in life. More than 50 percent of men in their sixties and as many as 90 percent in their seventies and eighties have some symptoms of BPH.
Most patients with BPH have trouble voiding. The most common symptoms that cause the most frustration and loss of quality of life are waking at night to urinate, and a sudden, strong and frequent urge to urinate. Other symptoms include a weak stream, dribbling after finishing, the sensation of incomplete bladder emptying, and pain or burning while urinating. The size of the prostate does not always determine the severity of a patient's symptoms.
Urinary obstruction can cause serious problems over time, including urinary tract infections, bladder or kidney damage, bladder stones and incontinence. Usually, it is the symptoms of the obstruction that causes the patient to seek treatment.
In the past, the coding of BPH had been confusing due to the fact that urinary obstruction, a routine symptom of BPH, was coded separately. In this case, how did you sequence the BPH and the urinary obstruction? To alleviate confusion, a combination code was created. The fifth digit describes whether or not urinary obstruction and other lower urinary tract symptoms (LUTS) are present.
The following codes are used to report BPH:
600.00 Hypertrophy (benign) of prostate WITHOUT urinary obstruction and other lower urinary tract symptoms (LUTS)
600. 01 Hypertrophy (benign) of prostate WITH urinary obstruction and other lower urinary tract symptoms (LUTS)
When reporting code 600.01, it is important to use additional codes from the list below to identify the LUTS associated with the BPH:
Incomplete bladder emptying (788.21)
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)
To code BPH correctly, first determine if symptoms are present. If they are present, assign 600.0 with a fifth digit of "1". Then code those symptoms in addition to the code for the BPH. If symptoms are not present, assign a fifth digit of "0."
According to Coding Clinic, if a patient presents with acute renal failure due to BPH and urinary obstruction, you should sequence the acute renal failure first, followed by code 600.01 and any documented LUTS.
Treatment of BPH
Treatment of BPH is usually reserved for men with bothersome symptoms. A digital rectal exam is often performed to check the size and firmness of the prostate. Often mild or moderate BPH may only require close monitoring. Drug therapy may be warranted, including alpha blockers or medications that inhibit testosterone. Most men find relief using drug therapy. If the patient is experiencing severe symptoms of urinary obstruction such as urinary retention, or if drug therapy fails, surgery may be necessary to prevent bladder or kidney damage. Surgery may also be warranted for those who have recurrent urinary tract infections and hematuria. The type of procedure performed is usually based on the severity of symptoms and the size and shape of the prostate gland.
The following transurethral procedures are commonly performed to relieve problematic symptoms. For the purposes of this article we will discuss only the ICD-9-CM procedure codes used to report these procedures:
60.21, Transurethral (ultrasound) guided laser induced prostatectomy (TULIP).
This procedure utilizes a laser to destroy prostatic tissue. Several small cuts are made in the bladder neck with the laser in order to reduce the prostate's pressure on the urethra, making urination easier. The entire prostate is treated. This code is also reported for visual laser assisted prostatectomy (VLAP).
60.29 Other transurethral prostatectomy.
Transurethral resection of the prostate (TURP) is the most common and most effective surgical treatment for BPH, and remains the procedure of choice even though the majority of the other procedures listed here are less invasive. A TURP is performed by inserting a scope through the penis; the prostate is treated with sharp excision, curette or other technique one piece at a time. Treatment with electrovaporization or TEVAP does essentially the same thing as a TURP, but uses electrical current to destroy the prostate tissue. Other descriptive terms to look for are enucleation and excision.
60.95 Transurethral balloon dilation of the prostatic urethra.
This procedure is performed to reduce the narrowing of the prostatic urethra by dilating the urethra. A prostatic dilation cystoscope and a balloon are placed in the urethra. After the balloon is positioned correctly, it is inflated and the pressure is maintained for ten minutes. The balloon is then deflated and removed. Balloon dilatation of the prostate is effective in patients with mild obstruction.
60.96 Transurethral destruction of prostate tissue by microwave thermotherapy.
This code is used to report transurethral microwave thermotherapy (TUMT). This procedure is used to treat symptomatic patients with mild to moderate BPH. After an endoscope is passed, a microwave thermotherapy stylet is inserted in the urethra and the diseased prostate is treated with electromagnetic radiation.
60.97 Other transurethral destruction of prostate tissue by other thermotherapy.
This code is used to report transurethral needle ablation (TUNA) of the prostate and radiofrequency thermotherapy. TUNA uses radiofrequency energy forthermal ablation to destroy prostatic tissue.
Cystoscopy is considered an inherent part of the procedures above and is not coded in addition to the primary procedure code.
Review the following Coding Clinics; 3Q 1992, p. 7, No. 5 1993, p. 9; 3Q 2002, p. 28; 3Q 2005 p. 20; and 4Q 2006, p. 93 for more information.
Test your knowledge on BPH and corresponding procedures with the following quiz:
1. A 70-year-old male is admitted with urinary retention. A TURP is performed and the diagnosis of benign nodular hyperplasia is made. Which of the following would be the appropriate diagnosis and procedure code(s) selection?
a. 600.01, 788.20, 60.29
b. 600.11, 788.20, 60.29
c. 600.00, 60.29
d. 600.10, 60.29
2. A patient presents with benign prostatic hypertrophy (BPH) with urinary frequency and bladder neck obstruction. A TULIP procedure and dilation of the bladder neck is performed. Which of the following would be the appropriate diagnosis and procedure code(s) selection?
a. 600.01, 596.0, 788.41, 60.21, 57.92
b. 600.00, 596.0, 60.21, 57.92
c. 600.00, 788.41, 60.21, 57.92
d. 600.01, 596.0, 788.41, 60.21
3. A patient is seen in the clinic with symptoms of urinary retention and incomplete bladder emptying secondary to benign prostatic hypertrophy (BPH). The patient is evaluated and referred to a urologist for evaluation. Which of the following would be the appropriate diagnosis code(s) selection?
a. 600.01, 788.20, 788.21
b. 600.00, 788.20, 788.21
d. 600.01, 788.21
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, facility solutions, Ingenix, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com). Ingenix develops software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the AHA.
CPT is a registered trademark of the AMA.
1. b: Code 600.11 is assigned to report the nodular hyperplasia with LUTS. Code 788.20 is assigned as a secondary diagnosis to report the symptom of urinary retention. A TURP was performed and reported with code 60.29.
2. a: 600.01 is assigned because lower urinary tract symptoms of the BPH are present. Secondary diagnosis codes 596.0 and 788.41 are assigned to report the bladder neck obstruction and the symptom of urinary frequency. Code 60.21 is reported for the TULIP procedure. Procedure code 57.92 is also reported for the dilation of the bladder neck. This procedure is not considered part of the TULIP but is a separate procedure.
3. a: If a patient with BPH has symptoms of urinary retention and incomplete bladder emptying, code 600.01 is assigned for the BPH with obstruction. Secondary diagnoses codes are also assigned identifying the associated lower urinary tract symptoms, urinary retention (788.20) and incomplete bladder emptying (788.21).