In simple words: This code represents a non-cancerous enlargement of the prostate gland, which is causing problems with urination.

Benign prostatic hyperplasia with lower urinary tract symptoms. Enlarged prostate with LUTS. Use additional code for associated symptoms, when specified: incomplete bladder emptying (R39.14), nocturia (R35.1), straining on urination (R39.16), urinary frequency (R35.0), urinary hesitancy (R39.11), urinary incontinence (N39.4-), urinary obstruction (N13.8), urinary retention (R33.8), urinary urgency (R39.15), weak urinary stream (R39.12).

Example 1: A 65-year-old male patient presents with increased urinary frequency, hesitancy, and a weak stream.Digital rectal exam reveals an enlarged prostate.The physician diagnoses benign prostatic hyperplasia with lower urinary tract symptoms., A 70-year-old male patient reports difficulty starting his urine stream and feeling like his bladder doesn't empty completely.He is diagnosed with benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS)., A 55-year-old male with a history of BPH experiences acute urinary retention.A catheter is placed to relieve the retention, and the diagnosis is BPH with LUTS and urinary retention. An additional code, R33.8, is used to specify the urinary retention.

Documentation should include physical exam findings (e.g., enlarged prostate on digital rectal exam), symptoms related to lower urinary tract function (e.g., frequency, hesitancy, straining, weak stream, incomplete emptying), and any diagnostic test results (e.g., urinalysis, uroflowmetry).

** ICD-10-CM code N40 includes adenofibromatous hypertrophy of prostate, benign hypertrophy of the prostate, benign prostatic hypertrophy, BPH, enlarged prostate, nodular prostate, and polyp of prostate. It excludes benign neoplasms of the prostate (D29.1) and malignant neoplasm of prostate (C61).