Coding Hematuria – A Common Urinary Disorder

by | Last updated May 17, 2023 | Published on Sep 7, 2020 | Medical Billing

Coding Hematuria
Share this:

Seeing blood in the urine can be quite alarming. Even though in many cases the exact causes are harmless, blood in the urine can indicate a serious disorder. The blood may be visible in such small quantities that it can’t be seen with the naked eyes. Also called hematuria, in this condition, blood in your urine can come from the kidneys or other parts of the urinary tract like the bladder and urethra. Ignoring hematuria can lead to serious conditions like kidney disease, cancer and other severe disorders. Hematuria is just a symptom of a serious health condition. So, the treatment will focus on the specific condition causing the symptoms. If left untreated urine infections can ultimately lead to kidney failure. Urology medical billing and coding can be challenging. Precise medical record documentation is vital for correct coding and billing for different urologic disorders. With appropriate documentation, medical billing and coding companies can help physicians select the correct ICD-10 codes and file clean claims for adequate reimbursement.

What Causes Hematuria?

In this condition, the kidneys and other parts of the urinary tract may allow blood cells to leak into the urine. In some cases, the blood may be from a different source. Blood can appear in the urine – in the vagina in women, the ejaculate in men, or from a bowel movement in either men or women. Various problems can cause this leakage like – urinary tract infections, presence of stones in the bladder or kidney, enlarged prostate, kidney infections (pyelonephritis), kidney disease, strenuous exercise, anti-cancer medications, cancer and other inherited disorders (like sickle cell anemia).

Types of Hematuria

There are two types of hematuria-

  • Gross hematuria – This type occurs when a person can see traces of blood in her/his urine and the urine appears pink or red or has spots of visible blood.
  • Microscopic hematuria – This occurs when a person cannot see the blood as the amount is so small. Only a laboratory test that detects blood by looking at a sample of urine under a microscope can confirm microscopic hematuria.

A pink, red, brownish-red, or tea-colored urine is one of the most common symptoms of the condition. People may not experience any other symptoms. However, they may experience severe bladder infections, kidney infections and stones. The condition is quite common among men above 50 years due to an enlarged prostate gland.

Diagnosing and Treating Hematuria

Diagnosis of this condition may begin with a detailed physical examination and medical history analysis. Before conducting a physical exam, urologists will ask question about the amount of blood in the urine and when patients see it during urination. They will also ask several questions about the frequency of urination, any pain while urinating, whether there are blood clots when urinating and what specific medications patients are consuming. Physicians will collect a sample of urine for testing. A urinalysis can confirm the presence of blood and detect bacteria if an infection is the cause. It can also check for a urinary tract infection or the presence of minerals that cause kidney stones. In addition, imaging tests like MRI scan, CT scan and ultrasound may be performed to find the cause of hematuria. In severe cases, urologists may perform a cystoscopy – which involves using a small tube to send a camera up to the urethra and into the bladder. With the camera, the physician can examine the interior of your bladder and urethra to determine the cause of your hematuria.

Patients who do not see blood in their urine but experience frequent, difficult, or painful urination, abdominal pain, or kidney pain, should immediately consult an urologist. In some cases, the exact cause of urinary bleeding cannot be detected. In such cases, urologists may recommend regular follow-up tests, especially if patients have risk factors for bladder cancer, such as smoking, exposure to environmental toxins or a history of radiation therapy. Treatment for this condition may depend on the type and the specific cause of hematuria. Treatment modalities involve antibiotics (to clear a urinary tract infection), prescription medications (to shrink an enlarged prostate) or shock wave therapy (to break up bladder or kidney stones).

Urologists providing treatment (that involves diagnosis, screening and other tests) for hematuria patients must carefully document the diagnosis and treatments using the right medical codes. Billing and coding services offered by experienced medical billing companies can help physicians ensure the correct codes for their medical billing purposes. ICD-10 codes for diagnosing hematuria include –

  • R31 Hematuria
  • R31.0 Gross hematuria
  • R31.1 Benign essential microscopic hematuria
  • R31.2 Other microscopic hematuria
  • R31.21 Asymptomatic microscopic hematuria
  • R31.29 Other microscopic hematuria
  • R31.9 Hematuria, unspecified

Ignoring the symptoms of hematuria can worsen the tumors to the point that treatment is difficult. In fact, untreated infections can lead to kidney failure. Timely treatment can help minimize the severity of symptoms. However, ignoring the same may lead to discomfort from having to urinate frequently, severe pain and even cancer (in extreme cases). Practicing good hygiene, drinking plenty of water, urinating immediately after sexual intercourse and refraining from smoking can help prevent the occurrence of this condition and other related infections in the long run.

Treating and managing hematuria patients can be quite challenging for urologists or other physicians. By outsourcing medical billing and coding tasks to reliable provider, physicians can ensure appropriate care for their patients as well as accurate clinical documentation of this urinary disorder.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

More from This Author