Remember a 7th Character When Citing Urethral Injury
Question: I have a urology report where the physician diagnosed the patient with acute urinary retention stemming from a urethral injury when the patient attempted to place a urinary catheter. The patient inserted the medically necessary catheter and accidentally injured their urethra in the process. How do we code this injury? Alabama Subscriber Answer: You’ll report three ICD-10-CM codes for this injury. Start with the urine retention, as this is the reason for the encounter. Assign R33.8 (Other retention of urine) to report the acute urine retention. A Code first note under the code instructs you to report a causal condition code first if it applies. If the patient was experiencing benign prostatic hyperplasia (BPH) and that was causing the urine retention, then you’d report an appropriate BPH code first, followed by R33.8. However, the patient experienced an injury rather than another condition that resulted in the retention. Next, you’ll need to code the issue that led to the retention. In your case, the patient unintentionally injured themselves while placing a urinary catheter for medical reasons. Use S37.30XS (Unspecified injury of urethra, sequela) to report the urethral injury. Lastly, depending on your payer’s preferences, you’ll report why or how the injury occurred. Assign Y73.3 (Surgical instruments, materials and gastroenterology and urology devices (including sutures) associated with adverse incidents) to indicate that a urology device was involved in the injury. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
