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ICD-10 Guide
ICD-10 CodesChapter 14: Diseases of the genitourinary systemN41

N41

Billable

Inflammatory diseases of prostate

Chapter 14:Diseases of the genitourinary system

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/18/2025

Code Description

ICD-10 N41 is a billable code used to indicate a diagnosis of inflammatory diseases of prostate.

Key Diagnostic Point:

Inflammatory diseases of the prostate encompass a range of conditions that primarily affect the prostate gland, leading to symptoms such as pelvic pain, urinary difficulties, and sexual dysfunction. The most common forms include prostatitis, which can be acute or chronic, and benign prostatic hyperplasia (BPH), characterized by an enlarged prostate that can obstruct urinary flow. Prostatitis may result from bacterial infections or other non-infectious causes, leading to inflammation and discomfort. BPH, while not an inflammatory condition per se, often coexists with prostatitis and can exacerbate urinary symptoms. Elevated prostate-specific antigen (PSA) levels are frequently associated with these conditions, serving as a marker for prostate health, although they are not definitive for cancer. Urological procedures, such as transurethral resection of the prostate (TURP) or prostate biopsies, may be indicated for severe cases or to rule out malignancy. Accurate coding for N41 requires a thorough understanding of the patient's clinical presentation and the specific type of inflammatory disease affecting the prostate.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between acute and chronic prostatitis
  • Understanding the relationship between BPH and prostatitis
  • Interpreting PSA levels and their implications
  • Identifying the need for urological procedures

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings
  • Failure to specify the type of prostatitis (acute vs. chronic)
  • Misinterpretation of PSA levels and their clinical significance
  • Lack of documentation for associated urological procedures

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed clinical notes on symptoms, diagnostic tests (including PSA levels), and treatment plans.

Common Clinical Scenarios

Patients presenting with urinary obstruction, pelvic pain, or recurrent urinary tract infections.

Billing Considerations

Ensure clarity in distinguishing between inflammatory and non-inflammatory prostate conditions.

Primary Care

Documentation Requirements

Comprehensive history and physical examination findings, including symptom duration and severity.

Common Clinical Scenarios

Men presenting with urinary symptoms or pelvic discomfort, often referred to urology for further evaluation.

Billing Considerations

Documenting the patient's complete medical history to rule out other causes of symptoms.

Coding Guidelines

Inclusion Criteria

Use N41 When
  • Follow official coding guidelines for N41, ensuring accurate documentation of the type of inflammatory disease, associated symptoms, and any relevant diagnostic tests
  • Include specific details about the patient's condition to support the chosen code

Exclusion Criteria

Do NOT use N41 When
No specific exclusions found.

Related CPT Codes

52601CPT Code

Transurethral resection of prostate

Clinical Scenario

Used for patients with severe BPH and prostatitis symptoms.

Documentation Requirements

Document indication for surgery, pre-operative assessments, and post-operative care.

Specialty Considerations

Urologists should ensure comprehensive documentation of the patient's history and the surgical rationale.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of inflammatory diseases of the prostate, improving the accuracy of diagnoses and treatment tracking. This specificity aids in better patient management and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of inflammatory diseases of the prostate, improving the accuracy of diagnoses and treatment tracking. This specificity aids in better patient management and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

Resources

Clinical References

  • •
    American Urological Association Guidelines

Coding & Billing References

  • •
    American Urological Association Guidelines

Frequently Asked Questions

What is the difference between acute and chronic prostatitis?

Acute prostatitis is a sudden onset of inflammation often caused by bacterial infection, presenting with severe symptoms. Chronic prostatitis, on the other hand, may develop gradually and can be due to persistent inflammation, often without a clear infectious cause.