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Home/Diagnosis/ICD-10 Coding for Difficulty in Urination

ICD-10 Coding for Difficulty in Urination

R39.1
N40.1

Complete ICD-10-CM coding and documentation guide for icd-10 coding for difficulty in urination includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Voiding Difficulty
Urinary Hesitancy
Straining to Urinate
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Key Information: ICD-10 Coding for Difficulty in Urination

Essential facts and insights about ICD-10 Coding for Difficulty in Urination

Use ICD-10 code R39.1 for other difficulties with micturition, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Other difficulties with micturition

Non-Billable
R39.1
Non-Billable

Diagnostic Criteria

  • • Patient reports difficulty with urination without pain.

Applicable To

  • • Urinary hesitancy
  • • Straining to urinate

Important Notes

  • • Ensure documentation specifies the nature of the difficulty, such as hesitancy or straining.

Benign prostatic hyperplasia with lower urinary tract symptoms

Billable Code
N40.1
Billable

Diagnostic Criteria

  • • Digital rectal exam indicating enlarged prostate
  • • IPSS score indicating LUTS

Applicable To

  • • BPH with LUTS

Important Notes

  • • Ensure that both prostate enlargement and LUTS are documented.
Ancillary Codes

Additional codes that may be used with this diagnosis

R30.0

Dysuria

Use if painful urination is also present.

R39.12

Poor urinary stream

Use to specify symptom of poor stream in BPH.

Frequently Asked Questions

What is the ICD-10 code for difficulty in urination?

The ICD-10 code for difficulty in urination is R39.1, which covers various micturition difficulties such as hesitancy and straining.

How is BPH with LUTS coded in ICD-10?

BPH with lower urinary tract symptoms is coded as N40.1 in ICD-10, requiring documentation of both prostate enlargement and LUTS.

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