What is the ICD-10 code for Benign Prostatic Hyperplasia (BPH) with hematuria requiring a Foley catheter?

ICD-10 Coding for BPH with Hematuria Requiring Foley Catheter

For BPH with hematuria requiring a Foley catheter, use N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms) as the primary code, with R31.0 (Gross hematuria) as a secondary code, and Z93.6 (Other artificial openings of urinary tract status) or Z46.6 (Fitting and adjustment of urinary device) to document the indwelling catheter.

Primary Diagnosis Coding

• N40.1 is the appropriate code for BPH with lower urinary tract symptoms, which encompasses the clinical scenario of prostatic bleeding requiring catheterization 1, 2
• The hematuria in this context represents a complication of the enlarged prostate causing mucosal trauma and vascular bleeding 3, 4

Secondary Diagnosis Codes

• R31.0 (Gross hematuria) should be added as a secondary code to specifically document the bleeding component 4, 5
• Z93.6 or Z46.6 documents the presence of the indwelling urinary catheter, which is medically necessary for managing both the urinary retention and ongoing hematuria 1, 6

Clinical Justification for Catheter Medical Necessity

The Foley catheter is medically justified in this scenario for multiple reasons:

• Acute urinary retention management: BPH commonly causes retention requiring immediate bladder decompression via urethral catheterization 6
• Hematuria with clot management: Significant hematuria from BPH may require catheterization to prevent clot retention and ensure adequate drainage 1, 3
• Monitoring and irrigation: Gross hematuria secondary to BPH may necessitate continuous bladder drainage, particularly when bleeding is significant enough to risk clot formation 1, 3

Additional Coding Considerations

• If the patient has acute urinary retention as the primary reason for catheterization, consider adding R33.9 (Retention of urine, unspecified) or R33.8 (Other retention of urine) 6
• If there is renal insufficiency secondary to obstruction, add N17.9 (Acute kidney failure, unspecified) or the appropriate chronic kidney disease code 1, 6
• For patients requiring long-term catheterization due to neurological injuries or complex bladder issues with significant hematuria, the documentation should clearly state the medical necessity 1

Common Pitfalls to Avoid

• Do not use N40.0 (Benign prostatic hyperplasia without lower urinary tract symptoms) when hematuria and catheter requirement are present, as these constitute LUTS 1, 2
• Always document the severity of hematuria (gross vs microscopic) and whether it required intervention such as catheterization, transfusion, or irrigation 3, 4
• Ensure proper evaluation has been documented to rule out bladder cancer, stones, or infection as alternative causes of hematuria before attributing it solely to BPH 3, 5
• Document failed medical management if applicable, as finasteride therapy is first-line for BPH-related hematuria, and catheter placement may indicate either acute presentation or treatment failure 4, 7