Outpatient Facility Coding Alert

ICD-10:

Details Help You Specify the Right Diagnosis for Urine Infection

Published on Thu May 19, 2016

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Take note: Clinical complications can make all the difference.

Your diagnosis code choices for urine retention under ICD-10 are not much different from what you were accustomed to in ICD-9. You do have expanded options that allow you to code with more specification, however, so it’s time to focus on your provider’s documentation.

Old system: When you still assigned diagnoses based on ICD-9, you had three options:

788.20 – Retention of urine, unspecified
788.21 – Incomplete bladder emptying
788.29 – Other specified retention of urine.

The “other” code 788.29 gets more specific in ICD-10.

ICD 10: The new diagnoses in ICD-10 are straightforward, but do offer a few more details than in years past. They are:

R33.9 – Retention of urine, unspecified
R33.8 – Other retention of urine
R33.0 – Drug induced retention of urine
R39.14 – Feeling incomplete bladder emptying.

Take note: Don’t miss some important coding guidelines included with the ICD-10. For example:

R33.8 instructs you to “Code first, if applicable, any causal conditions, such as enlarged prostate (N40.1)”
R33.0 states that you should “Use additional code for adverse effect, if applicable, to identify drug (T36-T50) with the fifth or sixth character.”
Category R33 excludes psychogenic retention of urine (F45.8, Other somatoform disorders).

The condition: To understand how ICD-10 codes have delved deeper, it’s important to understand exactly what urine retention is. Clinically speaking, urine retention involves:

A disorder characterized by accumulation of urine within the bladder because of the inability to urinate
Inability to empty the urinary bladder
Incomplete emptying of the bladder.

Watch for any of these details in your provider’s notes to help you pinpoint the most accurate diagnosis.