Benign prostatic hyperplasia without lower urinry tract symp

This code signifies an enlarged prostate gland that is not causing any bothersome urinary symptoms. It represents a histological diagnosis or imaging finding of prostatic enlargement without the patient experiencing issues such as frequency, urgency, nocturia, weak stream, or incomplete emptying.

Use this code when documentation clearly indicates benign prostatic hyperplasia (BPH) is present, but the patient denies or does not exhibit any associated lower urinary tract symptoms (LUTS). This is often identified incidentally during physical exams, imaging studies, or laboratory tests for other conditions.

• Do not use this code if any LUTS are documented; instead, select a code from N40.1- for BPH with LUTS.
• Ensure the physician's documentation explicitly states the absence of symptoms or describes the BPH as "asymptomatic."
• This code is often used for surveillance or management of BPH before symptoms develop or become significant.