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ICD-10 Guide
ICD-10 CodesN41.2

N41.2

Billable

Abscess of prostate

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

Code Description

ICD-10 N41.2 is a billable code used to indicate a diagnosis of abscess of prostate.

Key Diagnostic Point:

An abscess of the prostate is a localized collection of pus within the prostate gland, typically resulting from bacterial infection. It can occur as a complication of acute prostatitis or can develop independently, often associated with conditions such as benign prostatic hyperplasia (BPH) or other prostate disorders. Symptoms may include fever, chills, pelvic pain, dysuria, and urinary retention. Diagnosis is usually confirmed through imaging studies such as ultrasound or CT scans, which can reveal the presence of fluid collections. Treatment often involves antibiotics and may require surgical intervention to drain the abscess. Monitoring of prostate-specific antigen (PSA) levels is essential, as elevated PSA can indicate underlying prostate pathology, including abscess formation. The management of prostate abscesses is critical in preventing further complications, such as sepsis or chronic prostatitis, and requires a multidisciplinary approach involving urologists and primary care providers.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between acute prostatitis and abscess formation
  • Need for imaging studies to confirm diagnosis
  • Potential for surgical intervention complicating coding
  • Variability in clinical presentation and symptoms

Audit Risk Factors

  • Inadequate documentation of symptoms leading to diagnosis
  • Failure to document imaging studies performed
  • Lack of clarity on whether the abscess is a complication of prostatitis
  • Misclassification of abscess as a benign condition

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed clinical notes on symptoms, imaging results, and treatment plans.

Common Clinical Scenarios

Patients presenting with fever and pelvic pain, diagnosed with prostate abscess after imaging.

Billing Considerations

Ensure clear documentation of the abscess location and any surgical interventions performed.

Primary Care

Documentation Requirements

Comprehensive history and physical examination notes, including PSA levels and referral details.

Common Clinical Scenarios

Patients with urinary symptoms and elevated PSA referred to urology for further evaluation.

Billing Considerations

Document any prior treatments for prostatitis or BPH that may relate to the abscess.

Coding Guidelines

Inclusion Criteria

Use N41.2 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the abscess's clinical context
  • Include any relevant comorbidities and complications
  • infectious prostate disorders unless they are documented as contributing factors

Exclusion Criteria

Do NOT use N41.2 When
  • Exclude codes for non

Related ICD-10 Codes

Related CPT Codes

10060CPT Code

Incision and drainage of abscess

Clinical Scenario

Used when a prostate abscess requires surgical intervention.

Documentation Requirements

Document the procedure performed, including indications and findings.

Specialty Considerations

Urologists should ensure detailed operative notes are available.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of prostate conditions, including abscesses, which improves data accuracy and enhances patient care management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of prostate conditions, including abscesses, which improves data accuracy and enhances patient care management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of prostate conditions, including abscesses, which improves data accuracy and enhances patient care management.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the common symptoms of a prostate abscess?

Common symptoms include fever, chills, pelvic pain, dysuria, and urinary retention. Patients may also experience systemic signs of infection.

How is a prostate abscess diagnosed?

Diagnosis typically involves a combination of clinical evaluation, imaging studies such as ultrasound or CT scans, and laboratory tests including PSA levels.

What treatments are available for a prostate abscess?

Treatment often includes antibiotics and may require surgical drainage, especially if the abscess is large or causing significant symptoms.