Prostatectomy ICD-10-CM Codes | 2023

What ICD-10 Codes are used for Prostatectomy

ICD-10 codes, International Classification of Diseases, 10th Edition, are used to classify and assign codes to diseases, medical procedures, and other medical conditions. 

Prostatectomy, the surgical removal of the prostate gland, is assigned specific ICD-10 codes based on certain factors, such as the method used to operate (either open or laparoscopic), the purpose of the procedure, and any associated complications. 

To provide more clarity, here are the commonly used prostatectomy ICD-10 codes:

• N40.0 -  Benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS): In cases where medical treatment for BPH is not adequate, prostatectomy may be performed as a solution for severe cases.
• C61 - Malignant neoplasm of the prostate: Prostatectomy is a common treatment for prostate cancer, and this code may be used in such cases.
• Z90.46 - Acquired absence of another genitourinary organ: Used when a patient has undergone prostatectomy and other genitourinary organs are still intact.
• Z98.890 - Postprocedural states, other specified: Applied when the patient has undergone a prostatectomy, indicating a post-surgical state.
• N40.1 - Nodular prostate: Prostatectomy may be performed when nodules in the prostate are causing significant symptoms or suspicion of malignancy.
• N40.3 - Atrophy of prostate: Prostate atrophy may necessitate surgical intervention, and this code reflects that condition.
• Z41.2 - Encounter for prostate removal for neoplasm: Used when the encounter is specifically for the removal of the prostate due to cancer.
• Z98.52 - Prostate removal status: Indicates that the patient has undergone prostate removal, providing information about the patient's medical history.
• N40.4 - Cyst of the prostate: Prostatectomy may be performed in cases of a cyst in the prostate causing complications or symptoms.
• N42 - Other specified diseases of the prostate: Used when a prostatectomy is performed for conditions not covered by other specific codes, indicating a diverse range of prostate diseases.

These ICD-10 codes help standardize the documentation and billing processes related to prostatectomy procedures, ensuring accurate representation of the patient's medical condition and the healthcare services. Always consult the latest coding guidelines and updates for accurate coding practices.

Which Prostatectomy ICD Codes are billable

• N40.0 - Benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS): No. This code indicates a medical condition rather than a specific procedure.
• C61 - Malignant neoplasm of the prostate: Yes. 
• Z90.46 - Acquired absence of another genitourinary organ: No. This code is not specific to prostatectomy; it indicates the lack of another genitourinary organ.
• Z98.890 - Postprocedural states, other specified: Yes
• N40.1 - Nodular prostate: No. This code represents a medical condition rather than a specific procedure.
• N40.3 - Atrophy of prostate: No. Like N40.1, this code reflects a medical condition rather than a specific procedure.
• Z41.2 - Encounter for prostate removal for neoplasm: Yes. 
• Z98.52 - Prostate removal status: Yes. 
• N40.4 - Cyst of the prostate: No. This code represents a medical condition rather than a specific procedure.
• N42 - Other specified diseases of the prostate: No. Similar to N40.1 and N40.3, this code reflects a medical condition rather than a specific procedure.

Clinical information

• Prostatectomy is a surgical procedure used for treating prostate cancer and BPH, with various surgical techniques involved.
• Prostatectomy is indicated for confirmed prostate cancer and severe BPH symptoms, like urinary retention and recurrent infections.
• Before surgery, the patient's medical history is reviewed, and advanced imaging studies are conducted to determine the extent of prostate involvement. 
• PSA levels are also checked to assess cancer aggressiveness and guide treatment decisions.
• Prostatectomy techniques differ in approach and invasiveness. 
• Open prostatectomy uses a single incision, while laparoscopic prostatectomy is minimally invasive with small incisions and a camera. 
• Robotic-assisted prostatectomy offers heightened surgical control.
• General anesthesia ensures patient comfort and immobility during the procedure.
• After surgery, vigilant monitoring and pain management strategies are implemented along with postoperative urinary drainage using a catheter.
• Recovery and rehabilitation are integral components of the patient's journey post-prostatectomy. 
• Gradual resumption of normal activities, tempered with caution to avoid strenuous exercise initially, is coupled with follow-up appointments to monitor recovery progress and address emerging concerns. 
• Rehabilitation strategies may be implemented to address issues related to urinary continence and sexual function.
• Prostatectomy yields positive outcomes, offering improved urinary flow and symptomatic relief in cases of BPH, as well as serving as an effective treatment for localized prostate cancer. 
• However, it is not without potential side effects, including urinary incontinence and erectile dysfunction, the manifestation of which varies based on surgical techniques and individual patient factors.
• The long-term follow-up phase involves regular PSA testing to surveil for cancer recurrence, ongoing management of side effects or complications, and a collaborative approach with urologists and oncologists to ensure a holistic continuum of care, reflecting the multifaceted nature of prostatectomy in the realm of clinical interventions.

Synonyms include

• Prostatic surgery
• Prostate removal
• Prostate excision
• Radical prostatectomy
• Surgical prostate intervention