Look for These Documentation Clues to Keep Urinary Incontinence Claims Flowing
Know when it’s appropriate to query the provider. Urinary incontinence is one of the most common conditions treated in urology practices, yet it remains a frequent source of coding errors and payer denials. The challenge? It’s not a lack of ICD-10-CM codes, because there are many to choose from. But often, it’s documentation lacking specificity that forces coders to default to unspecified diagnoses. Continue reading to understand the clinical language urologists use and how that language maps to the correct incontinence codes for accurate reimbursement and audit defensibility. Understand the Major Categories of Urinary Incontinence ICD-10-CM classifies urinary incontinence primarily in the R32 (Unspecified urinary incontinence) through R39.- (Other and unspecified symptoms and signs involving the genitourinary system) code range and the N39.- (Other disorders of urinary system) code subcategory. Selecting the correct code depends almost entirely on how the provider describes the patient’s symptoms, triggers, and the underlying cause. Key: When reviewing documentation, look for clues as to what type of leakage is occurring, and under what circumstances. Stress urinary incontinence (SUI), also sometimes called mechanical incontinence, is leakage due to physical activity that puts pressure on the bladder. Urgency incontinence, also known as overactive bladder (OAB), is a sudden and frequent need to urinate even when the bladder may not be full. SUI vs. OAB — Or Both? Apply code N39.3 (Stress incontinence (female) (male)) when a patient experiences leakage while performing physical activity. Treatment focuses on improving the function of the urethral sphincter and strengthening the pelvic floor with lifestyle changes, physical therapy, pessaries, urethral bulking, or another minimally invasive procedure. Providers may describe it as activity-related leakage rather than using the term “stress incontinence.” Look for: Documentation for the diagnosis may include terms like: Codes N39.41 (Urge incontinence) and N32.81 (Overactive bladder) describe another principal presentation of incontinence, in which a patient’s sudden urge to urinate is caused by bladder contraction triggered by malfunction of the nerves between the bladder and the brain, not by physical activity or other external events. Treatment focuses on reducing those bladder contractions through lifestyle changes, physical therapy, medication, or certain urogynecological surgical procedures. Distinction: You may end up reporting one or both of the ICD-10-CM codes listed above, depending on the nuances of the case. A patient with an overactive bladder may not necessarily be incontinent. If leakage is occurring, N39.41 along with N32.81 would both be appropriate; but if there is urgency without leakage, report the OAB alone with N32.81. Look for: Documentation may include terms such as: Additionally: OAB can sometimes accompany SUI, so your coding may include both N39.3 and N32.81. However, if the record clearly supports both stress incontinence and urge incontinence with leakage, look to N39.46 (Mixed incontinence) instead of reporting both N39.41 and N39.3. Look for: Terms in the documentation that may support N39.46 include: Don’t Miss These Other Incontinence Dx Codes Overflow incontinence (N39.490 [Overflow incontinence]) occurs when the bladder can’t empty fully, often due to blockage, nerve damage, or weak bladder muscles, resulting in continuous leakage or dribbling. The condition is often secondary to benign prostatic hyperplasia (enlarged prostate) or neurogenic bladder, underlying conditions that may need to be coded separately. Terms to look for in the documentation that may support N39.490 include: Functional incontinence, coded with R39.81 (Functional urinary incontinence) describes urine leakage due to another condition preventing the patient from getting to the bathroom on time or a cognitive condition keeping the patient unaware of the need to urinate. Terms to look for in the documentation that may support R39.81 include: ICD-10-CM codes N39.45 (Continuous leakage) and R32 should only be used as a last resort. If the documentation provides any clues about timing, triggers, or mechanism, a more specific code is usually supported. Watch for: When incontinence is clearly linked to a prior procedure, coders should review whether a postprocedural code, such as N99.82- (Postprocedural hemorrhage of a genitourinary system organ or structure following a procedure) is more appropriate than a general incontinence diagnosis. Get Clarity Before Coding In urology, small documentation details have large coding consequences. Coders should consider querying providers when: A simple clarification can often move a claim from an unspecified code to a more precise, better-supported diagnosis. Jerry Salley, BA, MFA, Contributing Writer
