ICD-10 Codes for Reporting Two Common Urology Conditions

by | Published on Aug 9, 2021 | Medical Coding

Urology Conditions
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Affecting men, women, and children of all age groups, urology conditions refer to diseases of the male and female urinary tract. In females, they involve the urinary tract. In males, they affect the urinary tract or the reproductive organs. Generally, the condition may arise either 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. Diagnosing and documenting the various types of urologic disorders can be challenging for physicians. Precise medical record documentation is vital for correct coding and billing for different types of urologic disorders. With appropriate documentation, medical coding outsourcing companies can help physicians select the correct ICD-10 codes and file claims for adequate reimbursement.

Here discussed are two common urologic diseases and their ICD-10 codes –

Urinary Incontinence – Also called loss of bladder control, the condition occurs when the control over the urinary sphincter is either lost or weakened. The severity of the condition ranges from occasionally leaking urine when a person coughs or sneezes to having a strong and sudden urge to urinate. According to reports, about 15 million people in the United States suffer from urinary incontinence (2020 statistics). More common in females than in males, the condition can be caused by everyday habits, underlying medical conditions, or physical problems. It can occur due to stress factors such as coughing; it can happen during and after pregnancy and is more common in people with conditions such as obesity. The chances of urinary incontinence increase with age.

An occasional and minor leak of urine is one of the main symptoms. In certain other cases, people may lose small to moderate amounts of urine more frequently. Diagnosis of this condition begins with a thorough medical history evaluation and physical examination. Urologists may recommend different types of tests like urinalysis (to check for signs of infection or other abnormalities), post-void residual measurement, urodynamic testing and pelvic ultrasound. Treatment for urinary incontinence depends on the type of incontinence, its severity, and the underlying causes. A combination of treatments may be needed. If an underlying condition is causing the symptoms, that condition will have to be treated first. Common treatment options include medications, pelvic floor exercises, use of medical devices such as Urethral inserts, Sacral nerve stimulator, pessary; and surgery (in severe cases). Surgical procedures include – sling procedures, bladder neck suspension, artificial urinary sphincter and prolapse surgery. ICD-10 codes for urinary incontinence include –

  • N39.3 Stress incontinence (female) (male)
  • 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

Kidney Stones – Kidney stones are hard deposits made of minerals and salts (calcifications) that form inside the kidneys. As these hard 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 calculi, nephrolithiasis or urolithiasis, it can affect any part of the urinary tract – right from the kidneys to ureters, bladder or urethra. It 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). There is no single or definite cause for this condition, although several factors may increase the risk of kidney stones.

Typically, kidney stones will not cause any specific symptoms until these move around within the kidneys or pass into the ureters. Common symptoms include – severe, sharp pain in the side and back, below the ribs, pain that radiates to the lower abdomen and groin, pain or burning sensation while urinating, pink, red or brown urine, cloudy or foul-smelling urine, a persistent need to urinate, and nausea and vomiting. Diagnosis may begin with a detailed analysis which include – blood testing (to check the amount of calcium or uric acid in the blood) and urine testing. Imaging tests like – high-speed or dual energy computerized tomography (CT), abdominal X-rays and Ultrasound may be performed that would help reveal even tiny stones. 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. 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

Patients need to remain hydrated for maintaining urologic health. Urologists advise them to drink adequate amounts of water to enhance healthy urine flow to flush waste products from the body. In addition, patients are also advised to reduce the intake of sodium as it may cause water retention and disrupt the natural balance of minerals and other compounds.

Urology medical billing and coding can be challenging. Knowing the specific ICD-10 codes related to different urologic conditions is critical for providers. Partnering with a reputable medical billing company is a practical option for physicians to ensure accurate and timely claim submissions.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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