ICD-10 Codes for Reporting the Top Six Urologic Conditions

by | Published on Feb 26, 2020 | Medical Coding

Codes for Reporting the Top Six Urologic Conditions
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Regarded as a common condition that affects people of all age groups, urologic disorders encompass illnesses and diseases of the genitourinary tract. These disorders refer to illnesses of the male and female urinary tract, encompassing the kidneys, ureters, urinary bladder and urethra, as well as the male reproductive organs including testes, penis, and prostate. The disease may arise from the urinary system itself, or it could be secondary to a disease of another bodily system. It can be congenital or acquired and cancerous or benign, and they may predominantly concern men or women or both. Identifying, diagnosing, and documenting the various types of urologic disorders can be a complex task for physicians. Precise medical record documentation is vital for correct coding and billing for different types of 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.

Here are the top six urologic diseases and their ICD-10 codes –

Benign Prostatic Hyperplasia (BPH) – Regarded as a common condition in older men,
BPH is a non-cancerous increase in size of the prostate gland. Also called prostate gland enlargement, the condition can cause uncomfortable urinary symptoms, such as blocking the flow of urine out of the bladder, frequent or urgent need to urinate, inability to completely empty the bladder and increased frequency of urination at night (nocturia). Aging, family history of prostrate problems, diabetes, heart disease and other lifestyle habits can increase the risk of this condition. Treatment for prostate gland enlargement may begin with medications such as alpha-blockers and minimally invasive therapies. However, severe cases can be effectively treated with surgery.

ICD-10 codes to report BPH include –

  • N40 – Benign prostatic hyperplasia
    • N40.0 – Benign prostatic hyperplasia without lower urinary tract symptoms
    • N40.1 – Benign prostatic hyperplasia with lower urinary tract symptoms
    • N40.2 – Nodular prostate without lower urinary tract symptoms
    • N40.3 – Nodular prostate with lower urinary tract symptoms

Urinary incontinence – Urinary incontinence is the involuntary leakage of urine. It means control over the urinary sphincter is either lost or weakened. Reports suggest that about 15 million people in the United States suffer from urinary incontinence. The condition is more common in females than in males. It can occur due to stress factors, such as coughing, can happen during and after pregnancy, and is more common with conditions such as obesity. The chances of its occurrence increase with age. Treatment will depend on several factors, such as the type of incontinence, the patient’s age, general health, and may include options like – medications, pelvic floor exercises, use of medical devices (like – Urethral inserts, Sacral nerve stimulator, pessary) and surgery (in severe cases). ICD-10 codes for urinary incontinence include –

  • N39.4 – Other specified urinary incontinence
    • N39.41 – Urge incontinence
    • N39.42 – Incontinence without sensory awareness
    • N39.43 – Post-void dribbling
    • N39.44 – Nocturnal enuresis
    • N39.45 – Continuous leakage
    • N39.46 – Mixed incontinence
    • N39.49 – Other specified urinary incontinence
      • N39.490 – Overflow incontinence
      • N39.491 – Coital incontinence
      • N39.492 – Postural (urinary) incontinence
      • N39.498 – Other specified urinary incontinence

Urinary Tract Infections (UTIs) – A urinary tract infection (UTI) is an infection from microbes. Regarded as one of the most common types of  bacterial infections, UTIs are the result of pathogenic bacteria or viruses that invade the urinary tract and cause infection. They are much more common in women, although men can get them too. Women have a lifetime risk of over 50 percent of developing a urinary tract infection (UTI). Common symptoms include a strong, frequent urge to urinate and a painful and burning sensation when urinating. As UTIs are normally caused by bacteria, they are most commonly treated with antibiotics or antimicrobials. The type of medication and length of treatment will directly depend on the symptoms and medical history of the individual. Drinking lots of fluids and frequently urinating are always recommended for people who have UTIs as this helps to flush out the bacteria.

ICD-10 code for UTI

  • N39.0 – Urinary tract infection, site not specified

Kidney Stones – Kidney stones are the calcifications (body’s excess minerals and salts) that form inside your kidneys. As these substances begin to accumulate in the kidneys, they harden and form a crystal. As multiple crystals accumulate and join together in a more compact form, they end up with a pebble-like formation called a kidney stone. Also called renal lithiasis or nephrolithiasism, kidney stones have many causes and can develop anywhere along your urinary tract – in the kidneys, ureters, bladder or urethra. These can vary in size and shape and can start as small growths (as a grain of sand) and grow large (to the size of a golf ball). Treatment for this condition varies, depending on the type of stone and the cause.

In general, small kidney stones will not require any invasive form of treatment as these can be effectively managed by consuming more water. Medications like ibuprofen (Advil), acetaminophen (Tylenol), and naproxen sodium (Aleve) may help manage pain. On the other hand, stones that are too large to pass on their own because they cause bleeding, kidney damage or ongoing urinary tract infections may require more extensive treatments such as extracorporeal shock wave lithotripsy (ESWL), Tunnel surgery (percutaneous nephrolithotomy) and Ureteroscopy. ICD-10 codes to indicate a diagnosis of kidney stones include –

  • N20 – Calculus of kidney and ureter
    • N20.0 – Calculus of kidney
    • N20.1 – Calculus of ureter
    • N20.2 – Calculus of kidney with calculus of ureter
    • N20.9 – Urinary calculus, unspecified
  • N21 – Calculus of lower urinary tract
    • N21.0 – Calculus in bladder
    • N21.1 – Calculus in urethra
    • N21.8 – Other lower urinary tract calculus
    • N21.9 – Calculus of lower urinary tract, unspecified
  • N22 – Calculus of urinary tract in diseases classified elsewhere

Ureteral obstruction – Ureteral obstructions are common blockages that occur in one or both of your ureters. The ureters are two tubes that carry urine from each of your kidneys to your bladder. An obstruction in the ureters prevents urine from moving into your bladder and out of your body. Obstructions or blockages in the ureters can be either complete or partial. The condition is quite common in men, particularly as they age. Common symptoms include – abdominal pain on one or both sides (called flank pain), repeated urinary tract infections, leg swelling and difficulty urinating. Treatment for this condition includes measures to open up a blocked path and to treat the cause of the blockage. Antibiotics may also be prescribed to clear the associated infections. ICD-10 codes include –

  • N13.0 – Hydronephrosis with ureteropelvic junction obstruction
  • N13.1 – Hydronephrosis with ureteral stricture, not elsewhere classified
  • N13.2 – Hydronephrosis with renal and ureteral calculous obstruction

Prostate cancer (PC) – Regarded as the second most common non-skin cancers and the second leading cause of death in American men, prostate cancer (PC) affects the prostate gland (a small walnut shaped gland) that produces seminal fluid that nourishes sperm. In most cases, the exact causes of prostate cancer (PC) are not known. Urologists propose that PC occurs when some cells in the prostate gland become abnormal, causing them to grow and divide more rapidly than normal cells do. The abnormal cells continue living, (when other cells would die) and the accumulating abnormal cells form a tumor that can grow to invade the nearby tissue. Symptoms include – pain or burning sensation when urinating, frequent urination, dizziness, pain in the back, hip or pelvis, and blood in the urine. ICD-10 codes include –

  • C61 – Malignant neoplasm of prostate

Patients must schedule regular body checkups with their urologists to identify any specific symptoms they develop early. Staying hydrated is absolutely essential to urologic health. Patients need to drink lots of water as water naturally enhances healthy urine flow to flush waste products from the body. In addition, patients must reduce the intake of sodium (salt) as it may cause water retention and disrupt the natural balance of minerals and other compounds. Overloading on salt has also been linked to higher occurrences of kidney stones. Knowing the specific ICD-10 codes related to different urologic conditions is critical for providers. Partnering with an experienced urology medical billing company is a practical option for physicians to ensure accurate and timely claim submissions.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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