What CPT codes are used for BPH follow-up visits?

Use established patient E/M codes 99212-99215 based on MDM complexity. Most BPH follow-ups use 99213 (low complexity) for medication monitoring or 99214 (moderate complexity) for treatment changes or surgical planning. Add 51798 for bladder scan/PVR and 51741 for uroflow if performed. Document IPSS scores and medication response to support level selected.

What documentation supports BPH medication management?

Document: current symptoms with IPSS score (0-35), comparison to baseline, medication compliance, side effects (orthostatic symptoms for alpha-blockers, sexual side effects for 5-ARIs), PSA trends (note 5-ARI reduces PSA by ~50%), PVR measurements, and treatment response. Document reason for medication changes and expected timeline for improvement.

How should surgical intervention be documented for BPH?

Document: failed medical therapy (specific drugs, doses, duration), persistent symptoms despite treatment (IPSS score, QoL impact), objective findings (PVR >100-150mL, recurrent UTIs, urinary retention episodes, bladder stones, renal insufficiency), prostate size, and surgical options discussed with risks/benefits. Include patient's informed decision.

What monitoring is required for patients on 5-alpha reductase inhibitors?

Document: PSA at baseline and periodically (expect 50% reduction by 6 months—double measured PSA for cancer screening), sexual side effects assessment (ED, decreased libido, ejaculatory dysfunction), prostate size changes if measured, and symptom improvement. Warn patients about prolonged sexual side effects that may persist after stopping medication.

What documentation supports IPSS improvement claims?

Document: baseline IPSS score with date, current IPSS score, calculated change (point reduction and percentage), individual symptom changes if significant, QoL score comparison, and correlation with objective measures (uroflow Qmax, PVR). IPSS reduction of ≥3 points generally indicates clinically meaningful improvement. Track trends over multiple visits.

BPH Follow-up Template - Urology

Visit Information

Date: [Date]
Visit type: Follow-up
Last visit: [Date]
Time on current treatment: [X] weeks/months

Current Status

Overall: Better / Same / Worse
Primary concern today: [Symptoms, medication side effects, procedure planning]

Symptom Assessment

IPSS Score

Question	Score (0-5)
1. Incomplete emptying	[X]
2. Frequency	[X]
3. Intermittency	[X]
4. Urgency	[X]
5. Weak stream	[X]
6. Straining	[X]
7. Nocturia	[X]
Total IPSS	[X]/35

IPSS Trend:

Previous: [X] — Date: [X]
Current: [X]
Change: Improved / Stable / Worse

Quality of Life Score: [0-6]

0 = Delighted
6 = Terrible

Current Symptoms

Storage:

Frequency: [X] times/day — Change: [Better/same/worse]
Nocturia: [X] times/night — Change: [Better/same/worse]
Urgency: None / Mild / Moderate / Severe
Urge incontinence: None / [Frequency]

Voiding:

Stream strength: Normal / Weak / Very weak
Hesitancy: None / Mild / Significant
Intermittency: None / Present
Straining: None / Present
Incomplete emptying: None / Present
Post-void dribbling: None / Present

Other:

Dysuria: No / Yes
Hematuria: No / Yes
UTI since last visit: No / Yes — [Date, treatment]
Urinary retention: No / Yes — [Date, catheterization]

Current Treatment

Medications

Medication	Dose	Duration	Compliance	Efficacy
[Alpha-blocker]	[Dose]	[X] months	Good/Fair/Poor	[X]% improvement
[5-ARI]	[Dose]	[X] months	Good/Fair/Poor	[X]% improvement
[Other]	[Dose]	[X]

Side Effects

Alpha-blocker:

Orthostatic hypotension: No / Yes — [Severity]
Dizziness: No / Yes
Ejaculatory dysfunction: No / Yes
Nasal congestion: No / Yes

5-ARI:

Erectile dysfunction: No / Yes
Decreased libido: No / Yes
Gynecomastia: No / Yes

Other side effects: [List]

Adherence Issues

Taking as prescribed: Yes / No

Reason for non-adherence: [Cost, side effects, forgetting]

Sexual Function

Erectile function: Normal / Decreased / None
Ejaculation: Normal / Decreased volume / Retrograde / Anejaculation
Libido: Normal / Decreased
Sexually active: Yes / No
Concerns: [List]

Physical Examination

Vital Signs

BP: [X/X] — Orthostatic: [If on alpha-blocker]
HR: [X]
Weight: [X]

Focused Exam

Abdomen: Soft, non-tender
Bladder: Not palpable / Palpable

DRE

Prostate:

Size: Estimated [X] grams — Change: [Stable/enlarged]
Consistency: [Soft/firm]
Nodules: None / [New finding]
Tenderness: None / Present

Diagnostic Studies

Current Labs

PSA: [X] ng/mL — Date: [X]

Previous: [X] — Change: [Stable/increased/decreased]
Note: [5-ARI effect on PSA]

Creatinine: [X] (if checked)

Bladder Assessment

PVR: [X] mL — Date: [X]

Previous: [X] mL
Trend: Improved / Stable / Worsening

Uroflow (if performed):

Qmax: [X] mL/s
Voided volume: [X] mL
Pattern: [Bell-shaped/plateau/intermittent]

Imaging (if performed)

Renal US: [Date, findings]
Prostate volume: [X] cc (by US or MRI)

Assessment

1) BPH — [Response to current treatment]

Symptoms: Improved / Stable / Progressive
IPSS: [X] — [Mild/moderate/severe]
Obstruction: [Controlled/progressing]

2) [Secondary issues — retention risk, renal function, etc.]
Treatment response: Adequate / Inadequate

Plan

Medication Adjustment

[ ] Continue current regimen
[ ] Increase dose: [Medication, new dose]
[ ] Add medication: [Drug, dose]
[ ] Change medication: [From → To]
[ ] Discontinue: [Medication, reason]

Surgical Discussion (if indicated)

Surgical options reviewed: Yes / No

[ ] TURP
[ ] HoLEP
[ ] Greenlight laser (PVP)
[ ] Rezum (water vapor therapy)
[ ] UroLift
[ ] Aquablation
[ ] Simple prostatectomy

Patient preference: Continue medical / Consider surgery / Ready for surgery
Scheduled: No / Yes — [Procedure, date]

Monitoring

[ ] Routine follow-up
[ ] Labs: PSA, creatinine
[ ] PVR check
[ ] Uroflow
[ ] Urodynamics
[ ] Cystoscopy
[ ] Imaging: [Specify]

Referrals (if needed)

[ ] Urology surgery scheduling
[ ] Pre-operative evaluation
[ ] Other: [Specify]

Patient Education

Medication instructions reviewed
Side effects discussed
Symptoms requiring urgent evaluation
Surgical options (if applicable)

Follow-up

Return: [X] months

Routine BPH monitoring
Sooner if: Retention, gross hematuria, worsening symptoms, fever

Labs before next visit: [ ] PSA [ ] BMP

Urology — BPH Follow-up Template

Template