2025 ICD-10-CM code N41
Inflammatory diseases of prostate.
Medical necessity for the treatment of inflammatory prostate conditions is established by the presence of signs and symptoms consistent with the diagnosis.The documentation should support the severity of the condition and the need for medical intervention.
Diagnosis and treatment of inflammatory prostate conditions falls under the purview of urologists and primary care physicians.Responsibilities include performing physical exams, ordering and interpreting lab tests (e.g., urinalysis, cultures), and prescribing appropriate medication (e.g., antibiotics, pain relievers).For chronic cases, they may also manage long-term care, including lifestyle modifications and other therapies.
In simple words: This code represents a group of conditions causing inflammation of the prostate gland.
Inflammatory diseases of prostate. Use additional code (B95-B97) to identify infectious agent, if applicable.
Example 1: A 55-year-old male patient presents with fever, chills, and perineal pain. Upon examination, the prostate is found to be tender and swollen. A urinalysis reveals the presence of white blood cells and bacteria. The diagnosis is acute bacterial prostatitis (N41.0)., A 60-year-old male patient reports chronic pelvic pain, urinary frequency, and urgency.Following clinical evaluation and diagnostic testing (including ruling out other potential causes), he is diagnosed with chronic prostatitis (N41.1)., A 45-year-old male patient presents with severe perineal pain, fever, and difficulty urinating. A digital rectal exam reveals a fluctuant area on the prostate. Imaging studies confirm the presence of a prostatic abscess (N41.2).
Documentation should include details of the patient's symptoms (e.g., pain, urinary symptoms), findings from physical examinations (including a digital rectal exam), results of laboratory tests (urinalysis, cultures), and imaging studies (if performed).For chronic cases, documentation should also reflect the duration and impact of symptoms on the patient's quality of life.
** There are different types of prostatitis (acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis). Accurate diagnosis and documentation are essential for appropriate code assignment.
- Specialties:Urology, Primary Care
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Federally Qualified Health Center