Are my providers the only ones who state a diagnosis, but the documentation contains questions about it?! I'm uncertain whether urinary retention is clearly documented/supported in this note. How would you code this encounter for an older gentleman with a history of prostate surgery? (The question mark below is typed in by the provider.)
"Drinking water and decreased urine output. States has trouble getting urine out at times.
?urinary retention: Pt cathed and had 200 cc clear urine. Pt states he felt better. I do not feel pt needs indwelling catheter."
"A/P: Urinary retention, R33.9. Unclear if he had this. Pt cathed 200 cc of clear urine. Pt did not feel he needed or wanted a catheter. Advised to go to ER if he cannot urinate in a timely fashion. For now will send UA and culture. Follow up in 2 days."
Would you code retention...
...or use an R code to describe the symptoms? If the latter, which one fits the best?
R39.11, Hesitancy of micturition
R39.12 Poor urinary stream (weak stream)
R39.14 Feeling of incomplete bladder emptying
R39.16 Straining to void
Or is this worth a provider query?
Thanks so much for your help!
"Drinking water and decreased urine output. States has trouble getting urine out at times.
?urinary retention: Pt cathed and had 200 cc clear urine. Pt states he felt better. I do not feel pt needs indwelling catheter."
"A/P: Urinary retention, R33.9. Unclear if he had this. Pt cathed 200 cc of clear urine. Pt did not feel he needed or wanted a catheter. Advised to go to ER if he cannot urinate in a timely fashion. For now will send UA and culture. Follow up in 2 days."
Would you code retention...
...or use an R code to describe the symptoms? If the latter, which one fits the best?
R39.11, Hesitancy of micturition
R39.12 Poor urinary stream (weak stream)
R39.14 Feeling of incomplete bladder emptying
R39.16 Straining to void
Or is this worth a provider query?
Thanks so much for your help!