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v1.0.0
ICD-10 Guide
ICD-10 CodesN41.0

N41.0

Billable

Acute prostatitis

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

Code Description

ICD-10 N41.0 is a billable code used to indicate a diagnosis of acute prostatitis.

Key Diagnostic Point:

Acute prostatitis is an inflammatory condition of the prostate gland that occurs suddenly and is characterized by symptoms such as fever, chills, pelvic pain, and urinary difficulties. It is often caused by bacterial infections, which can be either acute or chronic. The condition may present with an enlarged prostate, leading to obstructive urinary symptoms, including dysuria, frequency, and urgency. Diagnosis typically involves a combination of clinical evaluation, laboratory tests, and imaging studies. Prostate-specific antigen (PSA) levels may be elevated in acute prostatitis, which can complicate the differential diagnosis with prostate cancer or benign prostatic hyperplasia (BPH). Treatment usually involves antibiotics, anti-inflammatory medications, and supportive care. In severe cases, hospitalization may be required for intravenous antibiotics and monitoring. Understanding the nuances of acute prostatitis is essential for accurate coding and appropriate management of patients, as it can significantly impact their quality of life and may lead to complications if not treated promptly.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between acute and chronic prostatitis
  • Understanding the relationship between PSA levels and prostatitis
  • Identifying co-existing conditions such as BPH
  • Variability in clinical presentation and symptoms

Audit Risk Factors

  • Inadequate documentation of symptoms and treatment
  • Misclassification of acute vs. chronic prostatitis
  • Failure to document laboratory results, including PSA levels
  • Inconsistent coding of associated urinary symptoms

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed documentation of symptoms, diagnostic tests, and treatment plans is essential. Urologists should document the patient's history, physical examination findings, and any imaging or laboratory results.

Common Clinical Scenarios

Urologists frequently encounter patients presenting with acute urinary retention, fever, and pelvic pain, often requiring urgent intervention.

Billing Considerations

Urologists must ensure that the documentation clearly distinguishes between acute and chronic prostatitis to avoid coding errors.

Primary Care

Documentation Requirements

Primary care providers should document the patient's presenting symptoms, any relevant medical history, and the results of initial examinations.

Common Clinical Scenarios

Common scenarios include patients presenting with urinary symptoms and fever, requiring referral to urology for further evaluation.

Billing Considerations

Primary care providers should be aware of the need for timely referrals and the importance of documenting the patient's response to initial treatment.

Coding Guidelines

Inclusion Criteria

Use N41.0 When
  • According to official coding guidelines, acute prostatitis is classified under N41
  • Coders should ensure that the diagnosis is supported by clinical documentation, including symptoms, laboratory results, and treatment plans

Exclusion Criteria

Do NOT use N41.0 When
  • Exclusion criteria include chronic prostatitis and other prostate disorders

Related ICD-10 Codes

Related CPT Codes

52000CPT Code

Cystoscopy

Clinical Scenario

Cystoscopy may be performed to evaluate urinary obstruction in patients with acute prostatitis.

Documentation Requirements

Document indications for the procedure, findings, and any interventions performed.

Specialty Considerations

Urologists should ensure that the procedure is justified based on clinical symptoms and diagnostic findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of prostatitis types, improving the accuracy of diagnoses and treatment tracking. N41.0 provides a clear distinction for acute cases, facilitating better patient management and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of prostatitis types, improving the accuracy of diagnoses and treatment tracking. N41.0 provides a clear distinction for acute cases, facilitating better patient management and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of prostatitis types, improving the accuracy of diagnoses and treatment tracking. N41.0 provides a clear distinction for acute cases, facilitating better patient management and resource allocation.

Resources

Clinical References

  • •
    American Urological Association Guidelines

Coding & Billing References

  • •
    American Urological Association Guidelines

Frequently Asked Questions

What are the common symptoms of acute prostatitis?

Common symptoms include fever, chills, pelvic pain, dysuria, urinary frequency, and urgency. Patients may also experience lower back pain and perineal discomfort.

How is acute prostatitis diagnosed?

Diagnosis is typically made based on clinical symptoms, digital rectal examination findings, and laboratory tests, including urinalysis and PSA levels.

What is the treatment for acute prostatitis?

Treatment usually involves antibiotics, anti-inflammatory medications, and supportive care. Severe cases may require hospitalization for intravenous antibiotics.