I1400: Benign Prostatic Hyperplasia (BPH), Step-by-Step

Step-by-Step Coding Guide for I1400: Benign Prostatic Hyperplasia (BPH)

1. Review of Medical Records

Objective: Identify if the resident has an active diagnosis of benign prostatic hyperplasia (BPH) during the assessment period.

Actions:

• Access the resident’s medical records, including physician progress notes, urology consults, diagnostic reports (e.g., ultrasound, prostate-specific antigen [PSA] tests), and medication records.
• Confirm that the diagnosis of BPH is documented and is actively being managed during the last 7 days, either through medication, procedures, or monitoring for symptoms such as urinary retention.

2. Understanding Definitions

I1400: Benign Prostatic Hyperplasia (BPH): BPH refers to the non-cancerous enlargement of the prostate gland, commonly seen in older men, leading to urinary symptoms such as difficulty in urination or increased frequency.

Examples of Active BPH:

• A resident on medication such as tamsulosin or finasteride for the treatment of BPH.
• A resident undergoing regular monitoring or having procedures such as catheterization due to urinary retention caused by BPH.

Illustration 1:

• Scenario: A resident is on tamsulosin for BPH and receives regular checkups for urinary retention.
• Result: I1400 is coded "Yes" to reflect the active management of BPH.

3. Coding Instructions

Step-by-Step:

• Step 1: Review the resident’s medical records for a diagnosis of BPH during the last 7 days.
• Step 2: Confirm that the diagnosis is active, meaning it requires ongoing treatment, monitoring, or has an impact on the resident’s condition (e.g., urinary symptoms).
• Step 3: If the resident has an active diagnosis of BPH, check I1400 as "Yes".
• Step 4: If BPH is not actively managed or there is no documented diagnosis within the assessment period, check I1400 as "No".

Illustration 2:

• Scenario: A resident with a history of BPH has regular catheterization due to urinary retention related to BPH.
• Result: I1400 is coded "Yes" to document the active management of BPH.

4. Coding Tips

• Exclude Inactive Diagnoses: Ensure that BPH is actively being treated or managed. A diagnosis of BPH from years ago that no longer requires treatment or monitoring should not be coded as active.
• Check for Active Management: BPH may be considered active if the resident is receiving medications, treatments, or undergoing regular assessments for the condition (e.g., catheterization or PSA tests).

5. Documentation

Objective: Ensure the presence of BPH is properly documented and reflected in the resident’s care plan.

Actions:

• Document the diagnosis of BPH, including any treatments or interventions (e.g., medications, procedures) used to manage the condition.
• Ensure that any complications or symptoms, such as urinary retention, are noted in the medical record.

Illustration 3:

• Scenario: A resident is treated with finasteride for BPH and has regular monitoring for urinary retention.
• Documentation: Ensure that the BPH diagnosis and ongoing treatment are clearly noted in the medical record, and code I1400 as "Yes".

6. Common Errors to Avoid

• Misclassifying Inactive Diagnoses: Do not code BPH if the condition is not actively being treated or monitored. A diagnosis without recent symptoms or treatment is not considered active.
• Incomplete Documentation: Ensure that the diagnosis and treatment of BPH are fully documented in the resident’s medical record. Do not code I1400 without proper documentation.

Illustration 4:

• Scenario: A resident’s chart lists BPH, but there has been no recent treatment or monitoring in the past 7 days.
• Error: Do not code I1400 for inactive diagnoses. If no treatment or management occurred during the assessment period, I1400 should be coded as "No".

7. Practical Application

• Example 1: A resident receiving medication to manage urinary symptoms related to BPH during the assessment period. I1400 is coded "Yes".
• Example 2: A resident with a past diagnosis of BPH but no recent symptoms or treatment. I1400 is coded "No".

Please note that the information provided in this guide for MDS 3.0 Item set I1400 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0.  

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding.  

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.