Chapter 14
DISEASES OF THE GENITOURINARY SYSTEM
Introduction
Codes for genitourinary diseases are found in Chapter 14 in ICD-10-CM. The genitourinary system (or the urogenital system) includes the organs and anatomical structures involved with reproduction and urinary excretion in both males and females. Female genitourinary disorders include pelvic inflammatory diseases, vaginitis, salpingitis, and oophoritis. Common male genitourinary disorders include prostatitis, benign prostatic hyperplasia, urogenital cancers, premature ejaculation, and erectile dysfunction.
The code blocks for Diseases of the Genitourinary System chapter are displayed in the table below.
ICD-10-CM Blocks
N00-N08
Glomerular Diseases
N10-N16
Renal Tubulo-Interstitial Diseases
N17-N19
Acute Kidney Failure and Chronic Kidney Disease
N20-N23
Urolithiasis
N25-N29
Other Disorders of Kidney and Ureter
N30-N39
Other Diseases of the Urinary System
N40-N53
Diseases of Male Genital Organs
N60-N65
Disorders of Breast
N70-N77
Inflammatory Diseases of Female Pelvic Organs
N80-N98
Noninflammatory Disorders of Female Genital Tract
N99
Intraoperative and Postprocedural Complications and Disorders of Genitourinary System, Not Elsewhere Classified
ICD-10-CM incorporates similar codes into related categories. For example, for urolithiasis the different sites where a calculus occurs are classified together in a code block created to group into one location all calculus-related codes for all sites. There is also a category that classifies all intraoperative and postprocedural complications of treatment for genitourinary disorders (N99) together, as well as a code block entitled Renal Tubulo-Interstitial Diseases (N10-N16) that classifies all types of pyelonephritis. For some conditions, terminology has been updated with changes made to several block and category titles to reflect the currently accepted diagnostic terminology.
In Chapter 14, diseases of the genitourinary system in both males and females are organized by site and then by specific disease or condition. Genitourinary disorders in diseases classified elsewhere are located in a separate category at the end of each code block. For example, category N08 Glomerular disorders in diseases classified elsewhere identifies glomerulonephritis, nephritis, and nephropathy in diseases classified elsewhere. In addition, certain genitourinary diseases are classified by etiology (e.g., due to transmissible infections) rather than by site in Chapter 14.
Exclusions
Neoplastic diseases, certain infectious and parasitic diseases, and conditions complicating pregnancy, childbirth, and the puerperium are examples of conditions classified in other chapters. Reviewing all of the chapter level exclusions provides information on conditions classified in other chapters.
At the chapter level, there are no Excludes1 notes; however, there are several Excludes2 notes for Chapter 14 directing the coder to report these conditions, when they are present, with codes from another chapter.
Excludes1
Excludes2
None
Certain conditions originating in the perinatal period (P04-P96)
Certain infectious and parasitic diseases (A00-B99)
Complications of pregnancy, childbirth, and the puerperium (O00-O9A)
Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)
Endocrine, nutritional, and metabolic diseases (E00-E88)
Injury, poisoning, and certain other consequences of external causes (S00-T88)
Neoplasms (C00-D49)
Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
Reclassification of Codes
Nongonococcal urethritis is not classified as an infectious and parasitic disease in Chapter 1, but as nonspecific urethritis, code N34.1, in Chapter 14. Incontinence is considered a disease rather than a symptom, so the codes for incontinence are listed in the genitourinary diseases chapter.
Revised Terminology
The clinical terminology used to describe genitourinary disorders in ICD-10-CM has been updated to reflect advances in medical diagnostics and treatment for conditions such as male erectile dysfunction. For example, instead of reporting impotence of organic origin, ICD-10-CM provides codes that identify the various causes of erectile dysfunction as seen in the table below.
ICD-10-CM
N52.01
Erectile dysfunction due to arterial insufficiency
N52.02
Corporo-venous occlusive erectile dysfunction
N52.03
Combined arterial insufficiency and corporo-venous occlusive erectile dysfunction
N52.1
Erectile dysfunction due to diseases classified elsewhere
N52.2
Drug-induced erectile dysfunction
N52.31
Erectile dysfunction following radical prostatectomy
N52.32
Erectile dysfunction following radical cystectomy
N52.33
Erectile dysfunction following urethral surgery
N52.34
Erectile dysfunction following simple prostatectomy
N52.35
Erectile dysfunction following radiation therapy
N52.36
Erectile dysfunction following interstitial seed therapy
N52.37
Erectile dysfunction following prostate ablative therapy
N52.39
Other and unspecified postprocedural erectile dysfunction
N52.8
Other male erectile dysfunction
N52.9
Male erectile dysfunction, unspecified
Chapter Guidelines
Coding guidelines include the coding conventions, the general coding guidelines, and the chapter-specific coding guidelines. Coding and sequencing guidelines for genitourinary diseases and complications due to the treatment of genitourinary diseases are incorporated into the Alphabetic Index and the Tabular List. To assign the most specific code possible, pay close attention to the coding and sequencing instructions in the Tabular List and Alphabetic Index, particularly the Excludes1 and Excludes2 notes. Detailed guidelines are provided for chronic kidney disease (CKD), which is classified based on stage of severity, described in the following table:
ICD-10-CM
CKD Severity Stages
CKD, Stage 1 (N18.1)
CKD, Stage 2 (N18.2) equates to mild CKD
CKD, Stage 3 (N18.30-N18.32) equates to moderate CKD
CKD, Stage 4 (N18.4) equates to severe CKD
CKD, Stage 5 (N18.5) excludes CKD requiring chronic dialysis
CKD, Stage 5 (N18.6) includes CKD requiring chronic dialysis (ESRD)
Coding and sequencing guidelines for chronic kidney disease in patients who have undergone a kidney transplant state:
•A kidney transplant status patient may still have some form of chronic kidney disease because the transplanted kidney may not fully restore kidney function
•The presence of CKD alone does not constitute a transplant complication
•Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0 Kidney transplant status
•If a transplant complication such as failure or rejection or other transplant complication is documented, see Section I.C.19.g for information on coding complications of a kidney transplant
•If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider
Section I.C.19.g of the ICD-10-CM guidelines provides guidance on coding kidney transplant complications:
•Assign code T86.1- for documented complications of a kidney transplant (e.g., transplant failure or rejection or other transplant complication). Code T86.1- should not be assigned for post kidney transplant patients who have chronic kidney disease (CKD) unless a transplant complication such as transplant failure or rejection is documented. The provider should be queried if the documentation is unclear as to whether the patient has a complication of the transplant
•Conditions that affect the function of the transplanted kidney, other than CKD, should be assigned a code from subcategory T86.1 Complications of transplanted organ, kidney along with a secondary code that identifies the complication
Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. The guidelines for coding patients with CKD and other serious conditions indicate that the sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the Tabular List.
General Documentation Requirements
Documentation requirements depend on the particular genitourinary disease or disorder. Some of the general documentation requirements are discussed here, but greater detail for some of the more common genitourinary system diseases will be provided in the next section.
In general, basic medical record documentation requirements include the severity or status of the disease (e.g., acute or chronic), as well as the site, etiology, and any secondary disease process. Physician documentation of the significance of any findings or confirmation of any diagnosis found in laboratory or other diagnostic test reports is necessary for code assignment.
ICD-10-CM requires specificity regarding the type and cause of the genitourinary disorder which must be documented in the medical record. Provider documentation should clearly specify any cause-and-effect relationship between medical treatment and a genitourinary disorder such as post-catheterization urethral stricture, or prolapse of vaginal vault after hysterectomy. Documentation in the medical record should specify whether a complication occurred intraoperatively or postoperatively, such as intraoperative versus postoperative hemorrhage. Precise documentation is also necessary to avoid confusion between disorders such as fibroadenosis or adenofibrosis of the breast and fibroadenoma of breast. It is important to make a clear distinction in the medical record documentation.
Many codes also require documentation of the site, including laterality (right, left, bilateral) for paired organs and the extremities, such as in the example below.
ICD-10-CM Code(s)
N60.01
Solitary cyst of right breast
N60.02
Solitary cyst of left breast
N60.09
Solitary cyst of unspecified breast
Chapter-Specific Documentation Requirements
In this section, categories, subcategories, and subclassifications for some of the more frequently reported genitourinary diseases are reviewed. Valid codes are listed and documentation requirements are identified. The focus is on conditions with additional pieces of specific clinical documentation required in order to select the correct diagnostic code(s). Although not all codes with significant documentation requirements are discussed, this section will provide a representative sample of the type of additional documentation needed for genitourinary diseases. The section is organized alphabetically by the topic.
Absent, Scanty and Rare Menstruation
Amenorrhea is the clinical term for absence of menstruation for at least three menstrual periods in a row. Amenorrhea is most commonly caused by pregnancy but may also be due to problems with the reproductive organs or the glands that regulate hormone levels. In these cases, treatment of the underlying condition usually resolves the amenorrhea.
Primary amenorrhea is used to describe the condition in girls whose menstruation hasn’t begun by the age of 16. Secondary amenorrhea is defined as the absence of menstrual periods for 6 months in a woman who had previously established regular menstrual periods.
Hypomenorrhea is the medical term used to describe unusually light menstrual flow. Women with hypomenorrhea have scanty periods or spotting during periods. There are various reasons responsible for this condition; one known cause is intrauterine adhesions after uterine surgery (e.g., myomectomy). Other causes of hypomenorrhea include hormonal imbalances (as in puberty or peri-menopause), uterine hypoplasia, long-term use of contraceptives, excessive stress, crash diets, and heavy exercise.
Oligomenorrhea describes infrequent menstruation in women with previously regular periods. Clinically, the diagnosis of oligomenorrhea is applied to women with menstrual periods occurring at intervals of greater than 35 days, with only four to nine periods in a year.
Although the practitioner may specifically diagnose either hypomenorrhea or oligomenorrhea in the medical documentation, hypomenorrhea is coded to oligomenorrhea.
Coding and Documentation Requirements
Identify the clinical condition:
•Amenorrhea
•Oligomenorrhea (includes hypomenorrhea)
Identify the type:
•Primary
•Secondary
•Unspecified
ICD-10-CM Code/Documentation
N91.0
Primary amenorrhea
N91.1
Secondary amenorrhea
N91.2
Amenorrhea, unspecified
N91.3
Primary oligomenorrhea
N91.4
Secondary oligomenorrhea
N91.5
Oligomenorrhea, unspecified
Documentation and Coding Example
Twenty-one-year-old Caucasian female presents to OB-GYN with concerns about a change in her menstrual flow. Patient states her periods have always been regular with quite a heavy flow since they started at the age of 13. She has had a 75 lb. weight loss in the past year and while she was dieting she noticed her periods were sometimes irregular but now they have become quite scanty as well. Average length is just 2 days and she needs only a thin pad. She cannot insert a tampon because her vagina is too dry. Temp 98.4, Pulse 76, Resp 12, BP 110/68, Ht. 65 Wt. 132 lbs. On examination, this is a well-developed, well-nourished young woman. Neck supple without lymphadenopathy. Thyroid smooth, normal in size. Heart rate regular with a soft mid systolic ejection murmur which patient states she has had all of her life. Breath sounds clear, equal bilaterally. Breast exam is unremarkable. Abdomen is soft, flat with good muscle tone. Patient states she has been exercising with a personal trainer for the past 3 months. Pelvic exam is completely unremarkable. Impression: Hypomenorrhea due to recent weight loss.
Plan: Check FSH, LH, estrogen, prolactin, thyroid, and insulin levels just to r/o hormone etiology. Patient is congratulated on her weight loss and encouraged to continue with her exercise routine and healthy eating. She is advised that her current weight is appropriate for her height and bone structure and she should not attempt to lose more.
Diagnosis: Secondary Oligomenorrhea/Hypomenorrhea.
Diagnosis Code(s)
N91.4
Secondary oligomenorrhea
Coding Note(s)
Hypomenorrhea is indexed to direct the user to see oligomenorrhea. Since oligomenorrhea and hypomenorrhea are reported with the same code, and the status as secondary or primary is an axis of classification selected in the code title, a single diagnosis code is reported.
Cystitis
Cystitis, or inflammation of the bladder, is most often caused by a bacterial infection of the urinary tract. Cystitis may also result from a reaction to certain drugs, radiation therapy, irritants such as long-term use of a catheter, or as a complication of another illness. Documentation in the medical record needs to specify the type and cause of the cystitis and identify any infectious agent or organism, such as E. coli. Proper coding also requires documentation of cystitis as with or without hematuria.
Cystitis caused by certain specific infectious organisms are coded differently within the infectious disease chapter and are not included in the genitourinary chapter, so careful review of the documentation is needed to identify certain conditions such as candidal cystitis, chlamydial cystitis, diphtheritic cystitis, gonococcal cystitis, monilial cystitis, trichomonal cystitis, and tuberculous cystitis. Prostatocystitis is coded to N41.3 and not in category N30.
Coding and Documentation Requirements
Identify the type of cystitis:
•Acute
–With hematuria
–Without hematuria
•Chronic
–Interstitial
»With hematuria
»Without hematuria
–Other chronic
»With hematuria
»Without hematuria
•Irradiation
–With hematuria
–Without hematuria
•Trigonitis
–With hematuria
–Without hematuria
•Other specified type
–With hematuria
–Without hematuria
•Unspecified
–With hematuria
–Without hematuria
Use additional code to identify any infectious agent.
Note: Some types of cystitis are classified in Chapter 1 Infectious and Parasitic diseases. See Alphabetic Index when causative organism is documented to determine whether a code from category N30 should be assigned.
ICD-10-CM Code/Documentation
N30.00
Acute cystitis without hematuria
N30.01
Acute cystitis with hematuria
N30.10
Interstitial cystitis (chronic) without hematuria
N30.11
Interstitial cystitis (chronic) with hematuria
N30.20
Other chronic cystitis without hematuria
N30.21
Other chronic cystitis with hematuria
N30.30
Trigonitis without hematuria
N30.31
Trigonitis with hematuria
N30.40
Irradiation cystitis without hematuria
N30.41
Irradiation cystitis with hematuria
N30.80
Other cystitis without hematuria
N30.81
Other cystitis with hematuria
N30.90
Cystitis, unspecified without hematuria
N30.91
Cystitis, unspecified with hematuria
Documentation and Coding Example
Twenty-nine-year-old Caucasian female is referred to Urology Clinic by her GYN for c/o ongoing urinary frequency, urgency, and pain. She was initially seen 3 months ago by her Internist for acute onset of symptoms and was prescribed Macrodantin for a UTI. Her symptoms improved but did not clear completely and she began to have pain with intercourse. She saw her GYN who diagnosed a yeast infection and prescribed Monostat. When her symptoms did not improve her GYN suggested she see a urologist. On examination, this is an anxious appearing, well-dressed woman who looks younger than her stated age. Voided UA was positive for blood, negative for protein, WBCs. Physical exam is unremarkable and informed consent obtained for cystoscopy. Patient positioned comfortably in dorsal lithotomy and cystoscope inserted without difficulty through the urethral meatus into the bladder. A patchy area of nonkeratinizing squamous metaplasia is easily identified at the trigone of the bladder by its glistening, fluffy white appearance. A biopsy is taken since patient does have hematuria. Remainder of the exam is unremarkable. Patient tolerated the procedure well and was interviewed after she had rested and gotten dressed. Advised patient she has acute urethrotrigonitis and biopsy should confirm that. Most appropriate treatment is Doxycycline 100 mg BID x 2 weeks for both she and her partner followed by Doxycycline 100 mg daily for 2 weeks for her. They should use a condom during intercourse for one month or abstain from intercourse altogether.
Diagnosis: Hematuria due to acute urethrotrigonitis
Diagnosis Code(s)
N30.31
Trigonitis with hematuria
Coding Note(s)
Urethrotrigonitis is listed as an included condition under the code for trigonitis, which includes both the acute and chronic forms of the disease. When coding cases of cystitis, an additional code is assigned for the infectious agent when it is identified in the medical record documentation.
Dysmenorrhea
Dysmenorrhea is the clinical term for menstrual cramps or painful menstruation. There are two types of dysmenorrhea: primary and secondary, which differ in age of onset and the severity of pain experienced. Primary dysmenorrhea is very common among adolescents with about 90% of adolescents reportedly suffering from the condition. Primary dysmenorrhea is cramping that is not associated with an identified underlying cause.
Secondary dysmenorrhea on the other hand, is menstrual pain associated with other diseases, such as pelvic infections, ovarian cysts, or endometriosis. Common causes of secondary dysmenorrhea include endometriosis, intrauterine devices, ovarian cysts, pelvic inflammatory disease, premenstrual syndrome or premenstrual dysmorphic disorder, tubo-ovarian abscess, and uterine leiomyoma or fibroids. Treatment for secondary dysmenorrhea depends on the underlying cause. Secondary dysmenorrhea is less common, affecting about 25% of women with dysmenorrhea.
Differentiating primary dysmenorrhea from secondary dysmenorrhea is essential for correct code assignment. Psychogenic dysmenorrhea is coded elsewhere.
Coding and Documentation Requirements
Identify type:
•Primary dysmenorrhea
•Secondary dysmenorrhea
•Unspecified
ICD-10-CM Code/Documentation
N94.4
Primary dysmenorrhea
N94.5
Secondary dysmenorrhea
N94.6
Dysmenorrhea, unspecified
Documentation and Coding Example
Thirty-four-year-old Caucasian female presents to OB-GYN for her annual exam and has a new complaint of menstrual cramps. Patient has a history of endometriosis, diagnosed incidentally during an elective laparoscopic tubal ligation 2 years ago. She had no menstrual discomfort until now. The only change in her medical history is a benign cyst on her thyroid gland discovered by her PCP 8 months ago. Current medication is Tylenol for her pain. She did take meclizine and antibiotics for an ear infection with vertigo about 6 weeks ago. On examination, this is a tall, thin, attractive woman who looks her stated age. Neck supple, thyroid smooth with slight fullness on the left. Heart rate regular, breath sounds clear and equal. Breast exam is unremarkable. Abdomen soft, no pain with palpation. External genitalia normal. Speculum inserted without difficulty into vagina. Vaginal mucosa normal color, no discharge noted. Cervical os is closed. Cells collected for cytology and also HPV culture. Bimanual exam causes marked discomfort for patient. There is cervical motion tenderness and nodularity is appreciated in the cul de sac and around both ovaries. Rectal exam shows good sphincter tone but again marked discomfort during the exam.
Impression: Dysmenorrhea due to endometriosis.
Plan: Patient is given samples of Seasonique to take continuously for 3 months and advised to use ibuprofen instead of acetaminophen for pain. She will have blood drawn for CBC, ESR, and HCG to r/o infection, inflammation, or pregnancy. Return in 3 months for recheck, sooner if symptoms become worse.
Diagnosis: Dysmenorrhea due to endometriosis.
Diagnosis Code(s)
N94.5
Secondary dysmenorrhea
N80.9
Endometriosis, unspecified
Coding Note(s)
ICD-10-CM makes a distinction between primary and secondary dysmenorrhea. An additional code is assigned to report the endometriosis. Endometriosis is classified by site, but because the documentation does not describe the endometriosis or identify the site, the unspecified code must be assigned.
Hydronephrosis
Hydronephrosis is a condition in which the kidney’s urine collecting system becomes dilated, usually due to an underlying illness or medical condition. In hydronephrosis, distention of the kidney with urine is caused by the backward pressure placed on the kidney when the flow of urine is obstructed. Obstruction or blockage is the most frequent cause of hydronephrosis, but the condition may also be congenital or occur as a response to pregnancy, or it may be caused by trauma, neoplastic disease, calculi, inflammatory processes, or surgical procedures. Documentation of the etiology is essential for code assignment.
Careful review of the medical record documentation is necessary to assign the correct code. For example, calculus of the kidney and ureter without hydronephrosis must be distinguished from cases with hydronephrosis. Other examples include congenital obstructive defects of the renal pelvis and ureter, and obstructive pyelonephritis. All of these conditions are coded differently.
Obstruction can occur anywhere from the urethral meatus to the calyceal infundibula and the physiological effects depend on the level of the obstruction, the extent of involvement, the patient’s age at onset, and whether it is acute or chronic. Medical record documentation identifying the location of the obstruction is needed for code assignment. Hydronephrosis can also be unilateral involving just one kidney or bilateral involving both, although specific code selection does not require laterality.
Clinically, the term hydronephrosis describes dilation and swelling of the kidney, while the term hydroureter describes swelling of the ureter. These conditions, along with congenital hydronephrosis, are coded differently and therefore need to be clearly differentiated in the documentation.
Acquired hydronephrosis is a combination code that identifies the underlying medical condition causing the obstruction of urine and the resulting distension of the kidney.
Coding and Documentation Requirements
For acquired hydronephrosis, identify type of obstruction present:
•With infection
•With renal and ureteral calculous obstruction
•With ureteral stricture
•With ureteropelvic junction obstruction
•Other hydronephrosis
Unspecified hydronephrosis
ICD-10-CM Code/Documentation
N13.0
Hydronephrosis with ureteropelvic junction obstruction
N13.1
Hydronephrosis with ureteral stricture, not elsewhere classified
N13.2
Hydronephrosis with renal and ureteral calculous obstruction
N13.30
Unspecified hydronephrosis
N13.39
Other hydronephrosis
N13.4
Hydroureter
N13.6
Pyonephrosis
Note: Pyonephrosis reports hydronephrosis/hydroureter with infection.
Documentation and Coding Example
Twenty-four-year-old male patient presents to ED with c/o worsening left flank pain with nausea and vomiting for the past 2 hours. PMH is significant for kidney stone at age 20 that resolved without intervention. Patient states he is a professional backup dancer for a well-known recording artist who performed locally this evening. On examination, this is a well-developed, well-nourished Black male who looks exhausted from recent physical exertion. Temp 99, Pulse 70, Resp 14, BP 102/66, O2 sat 99%. PERRL, neck supple. HR regular, breath sounds clear and equal. CVA tenderness present on left side with fullness detected in the kidney area. Abdomen soft with decreased bowel sounds. Liver and spleen not palpated. IV started in right forearm infusing LR. UA obtained and blood drawn for CBC, comprehensive metabolic panel. Medicated with MS and Phenergan with patient reporting decreased pain and nausea. Urology consult obtained and Spiral CT ordered. Patient is comfortable while waiting for CT scanner to be available.
Urology Note: Patient was examined after CT scan. He is resting comfortably after repeat IV morphine sulfate. Spiral CT shows a stone in the left ureter with subsequent hydronephrosis of the left kidney. Movement of the stone is noted from the time lapse of the scan with the stone now mid-way between the kidney and bladder. It should clear the ureter and enter the bladder in a few hours. Labs are unremarkable other than UA showing a slightly elevated pH and microscopic hematuria. Patient admitted to medical floor for continued IV hydration and pain management. Strain all urine and send all solid material to lab for analysis.
Diagnosis: Unilateral hydronephrosis secondary to mid ureteral calculus
Diagnosis Code(s)
N13.2
Hydronephrosis with renal and ureteral calculous obstruction
Coding Note(s)
A combination code reports both the hydronephrosis and the obstruction due to the ureteral calculus.
Male Infertility
Male infertility is defined as an inability to achieve pregnancy in a fertile female after one year of unprotected intercourse. The scope of male infertility is widespread. An estimated 15% of couples are considered infertile, with approximately 30%-40% due to male factors alone, and 20% due to a combination of female and male factors. The quality and the quantity of sperm greatly influence reproductive outcomes. Male infertility may be due to low or absent sperm production, immobile sperm, or blockages in the delivery of sperm. Other factors that can play a role in causing male infertility include illnesses, injuries, and chronic health problems.
Azoospermia describes a complete absence of sperm in the ejaculate, while hypospermatogenesis is abnormally decreased spermatozoa production. Because germ cells are precursors to spermatozoa, germ cell aplasia is often the cause of nonobstructive azoospermia.
Coding and Documentation Requirements
Identify the specific type and cause of infertility:
•Azoospermia
–Due to extratesticular cause
»Drug therapy
»Infection
»Obstruction of efferent ducts
»Other extratesticular causes
»Radiation
»Systemic disease
–Organic
•Oligospermia
–Due to extratesticular cause
»Drug therapy
»Infection
»Obstruction of efferent ducts
»Other extratesticular causes
»Radiation
»Systemic disease
–Organic
•Other male infertility
•Unspecified male infertility
For extratesticular causes, code also associated cause.
ICD-10-CM Code/Documentation
N46.01
Organic azoospermia
N46.021
Azoospermia due to drug therapy
N46.022
Azoospermia due to infection
N46.023
Azoospermia due to obstruction of efferent ducts
N46.024
Azoospermia due to radiation
N46.025
Azoospermia due to systemic disease
N46.029
Azoospermia due to other extratesticular causes
N46.11
Organic oligospermia
N46.121
Oligospermia due to drug therapy
N46.122
Oligospermia due to infection
N46.123
Oligospermia due to obstruction of efferent ducts
N46.124
Oligospermia due to radiation
N46.125
Oligospermia due to systemic disease
N46.129
Oligospermia due to other extratesticular causes
N46.8
Other male infertility
N46.9
Male infertility, unspecified
Documentation and Coding Example
Fifty-two-year-old Caucasian male is referred to PMD for comprehensive physical as part of an infertility work up. Patient was able to father 3 healthy children with his first wife but his new wife has been unable to get pregnant despite unprotected intercourse x 8 months. His wife’s work up has been benign thus far. Patient comes reluctantly to the appointment because he has an extremely busy work schedule. He travels in the continental US frequently and goes to Europe and/or Asia at least once a month. Accessibility is not a problem as his wife travels with him, nor does performance appear to be an issue. He states that he is able to maintain an erection, penetrate, and ejaculate. A recent semen analysis showed a very low sperm count but the sperm present in the ejaculate were healthy and motile.
Temp 97.6, Pulse 80, Resp 12, BP 142/90, Ht. 72 inches, Wt. 184 lbs. His Blackberry and phone vibrate every few minutes and although he does not answer them, he is clearly distracted by the interruptions and is anxious to get the exam over with. He had a company nurse draw blood and he provided a urine sample prior to this visit so lab results are available. His only medication is occasional OTC Tagamet and Tums for heartburn. On examination, this is a well-developed, well-nourished man who looks younger than his stated age. PERRL, neck supple without lymphadenopathy. Nares patent, mucous membranes moist and pink. Cranial nerves grossly intact. Pulses and reflexes normal in extremities. Heart rate regular without bruit, rub, murmur. Breath sounds clear, equal bilaterally. Abdomen soft, bowel sounds present. Liver palpated at 3 cm below RCM, spleen at 1 cm below LCM. No evidence of hernia, testicles smooth. Penis is circumcised without urethral drainage. Rectal exam shows good sphincter tone with a smooth, normal size prostate gland.
Patient allowed to dress and labs are reviewed with him seated in the consultation room. Of significance his FBGL is 125 and HgbA1C is 7.1. TSH is 5.8. Lipid and triglyceride levels are in high normal range but liver and renal function tests are mildly elevated. Patient admits to smoking 2-3 cigarettes daily, cigars 1-2 x week. His alcohol consumption includes 2-4 oz. of Scotch and 2-3 glasses of wine per day.
Impression: Low sperm count due to underlying hypothyroid and insulin resistant diabetes Type II.
Plan: Patient is given samples and a prescription for Synthroid 0.05 mg to take daily in the AM at least 30 minutes before breakfast. He is given samples and a prescription for Metformin 500 to be taken 2 x day with meals. He is advised to stop smoking, cut down on his alcohol consumption, and avoid taking Tagamet as all 3 of these can decrease sperm count. He is to repeat labs in 1 month and call at his convenience to discuss results. This note is electronically sent to his wife’s infertility doctor. Further arrangements should be made with them for semen analysis.
Diagnosis: Hypospermatogenesis due to systemic disease.
Diagnosis Code(s)
N46.125
Oligospermia due to systemic disease
E11.69
Type 2 diabetes with other specified complication
E03.9
Hypothyroidism, unspecified
Z72.0
Tobacco use
Coding Note(s)
There is a specific code for infertility due to systemic disease; in this case, hypospermatogenesis, or oligospermia. Code(s) that specifically identify the systemic disease(s) present are coded additionally. The low sperm count is attributed to both hypothyroidism and type 2 diabetes. The type of hypothyroidism is not specified, and since there is no diabetes combination code specifically for reporting that occurring with infertility as a complication, the code for type 2 diabetes with other specific complication is assigned.
Redundant Prepuce and Phimosis
Phimosis is the inability of the prepuce or foreskin to be retracted behind the glans penis in uncircumcised males. This tightening of the foreskin may close the opening of the penis. Circumcision is the most common treatment to correct phimosis. In paraphimosis, the foreskin is retracted behind the crown of the penis which may cause entrapment of the penis, impairing blood flow.
Phimosis can be congenital or it may be due to infection. The symptoms of phimosis and paraphimosis are similar to other medical disorders, so clear documentation of the patient’s condition is necessary. When the cause of the phimosis or paraphimosis is infection, the medical record documentation should also identify the infectious agent.
When balanitis (inflammation of the glans) and posthitis (inflammation of the foreskin) occur together, it is called balanoposthitis. Correct coding requires documentation clearly describing the patient’s condition. Balanoposthitis is classified as a disorder of the prepuce and is reported within category N47 Disorders of prepuce, which provides specific codes for adherent prepuce of newborn, phimosis, paraphimosis, deficient foreskin, benign cyst, adhesions, and balanoposthitis. There is an additional code for other inflammatory disease of the prepuce and another code for other disorders (noninflammatory) of the prepuce.
Coding and Documentation Requirements
Identify type of prepuce disorder:
•Adherent prepuce, newborn
•Adhesions of prepuce and glans penis
•Balanoposthitis
•Benign cyst of prepuce
•Deficient foreskin
•Paraphimosis
•Phimosis
•Other disorders of prepuce
•Other inflammatory disease of prepuce
Use additional code as needed to identify any infectious agent.
ICD-10-CM Code/Documentation
N47.0
Adherent prepuce, newborn
N47.1
Phimosis
N47.2
Paraphimosis
N47.3
Deficient foreskin
N47.4
Benign cyst of prepuce
N47.5
Adhesions of prepuce and glans penis
N47.6
Balanoposthitis
N47.7
Other inflammatory diseases of prepuce
N47.8
Other disorders of prepuce
Documentation and Coding Example
Patient is an 18-month-old Hispanic male brought to ED by his grandmother and older sister. Parents are out of the country. Child is crying and appears uncomfortable. Through an interpreter, sister states her little brother woke this morning fussy and when she removed his diaper she saw that the tip of his penis was swollen. Child is seen immediately by the pediatric resident. On examination, the glans penis is red and swollen with an edematous, proximally retracted foreskin forming a circumferential constricting band. The penile shaft is soft and there is no evidence of necrosis in the glans or the shaft. EMLA cream is applied liberally to the penis, patient placed on monitors, and medicated with Demerol IM. Manual compression of the glans penis and foreskin x 10 minutes allows the foreskin to be easily reduced over the glans using gentle pressure. Patient monitored following procedure and discharged home in good condition. Family is given instructions for care/cleaning of uncircumcised penis and will follow up in Urology Clinic in one week.
Diagnosis: Paraphimosis.
Diagnosis Code(s)
N47.2
Paraphimosis
Salpingitis/Oophoritis
Salpingitis is an inflammation of the fallopian tubes and oophoritis is an inflammation of the ovaries. The two conditions are often seen in combination. Salpingitis and oophoritis are specified as acute or chronic. In chronic cases, the swelling and inflammation is often caused by a hydrosalpinx, which is the accumulation of fluid within the fallopian tube caused by a blockage at the distal end. The condition can affect one or both sides. Hydrosalpinx is an included condition for chronic cases.
ICD-10-CM provides separate codes for salpingitis alone and oophoritis alone. Conditions classified with salpingitis and/or oophoritis include:
•Abscess
–Fallopian tube
–Ovary
–Tubo-ovarian
•Pyosalpinx
•Salpingo-oophoritis
•Tubo-ovarian inflammatory disease
An additional code is used to report the causative infectious organism(s), when it is identified.
Coding and Documentation Requirements
Identify the condition:
•Salpingitis alone
•Oophoritis alone
•Salpingitis and oophoritis
Identify the status of the condition:
•Acute
•Chronic
•Unspecified
ICD-10-CM Code/Documentation
N70.01
Acute salpingitis
N70.02
Acute oophoritis
N70.03
Acute salpingitis and oophoritis
N70.11
Chronic salpingitis
N70.12
Chronic oophoritis
N70.13
Chronic salpingitis and oophoritis
N70.91
Salpingitis, unspecified
N70.92
Oophoritis, unspecified
N70.93
Salpingitis and oophoritis, unspecified
Documentation and Coding Example
Thirty-nine-year-old Caucasian female referred to radiology by her OB-GYN for pelvic ultrasound and possible hysterosalpingogram. Patient is a G1P1 who has been trying to conceive a second child for over a year without success. Her first child is 6 years old and conceived without difficulty. That pregnancy was uncomplicated with a spontaneous vaginal delivery. Her GYN exams are WNL with no history of PID or endometriosis. Husband’s sperm quality is excellent. Informed consent obtained and pelvic US using vaginal probe shows a normal cervix and uterus, normal appearing ovary on the right but no visible tube. The view of the left ovary is somewhat obscured due to a large cylinder-shaped collection of fluid in the area of the left fallopian tube. Discussed findings with patient and decision made to proceed with HSG. Patient transferred to fluoroscopy suite where she is prepped and draped for the procedure. Catheter easily inserted through cervix into uterus and contrast injected. Uterine filling is normal, the right fallopian tube fills and spills contrast into the peritoneum within 5 minutes. The left fallopian tube has partial filling at the proximal end but appears large and bulbous past that area. Delayed films are obtained 15, 30, and 45 minutes post contrast injection and still show no dye spill from the distal end of the left fallopian tube.
Impression: Hydrosalpinx of left fallopian tube. Report and procedure note is electronically sent to referring physician. Results also discussed with patient who will follow up with her OB-GYN.
Diagnosis: Hydrosalpinx.
Diagnosis Code(s)
N70.11
Chronic salpingitis
Coding Note(s)
Hydrosalpinx is classified as an inclusion to subcategory N70.1-. Chronic salpingitis and oophoritis. Hydrosalpinx is indexed to code N70.11, specifically for chronic salpingitis.
Spermatocele
A spermatocele is a cyst on the epididymis usually filled with fluid and dead sperm cells. These spermatic cysts may occur alone or as multiple cysts. ICD-10-CM provides specific codes for spermatocele of the epididymis to identify the occurrence as single, multiple, or unspecified.
Coding and Documentation Requirements
Identify the occurrence of spermatocele:
•Multiple
•Single
•Unspecified
ICD-10-CM Code/Documentation
N43.40
Spermatocele of epididymis, unspecified
N43.41
Spermatocele of epididymis, single
N43.42
Spermatocele of epididymis, multiple
Documentation and Coding Example
Twenty-three-year-old male presents to urologist concerned about a painless lump he discovered in his scrotum when he did a testicular self-exam. He has practiced TSE since the age of 17 when his brother-in-law was diagnosed with testicular cancer. Patient is a graduate student in International Relations and an elite cyclist on his college team. On examination, this is a muscular, but thin young man. He is very intense, extremely articulate, and able to provide a detailed health history on both himself and his family. On examination, the abdomen is very firm and muscular. He denies pain with palpation. There is no evidence of hernia in the inguinal area. Penis is circumcised, no urethral drainage. Scrotum has normal rugae. Left testicle is smooth and slightly higher than the right. The right testicle is also smooth with a soft, spherical, well circumscribed fullness in the epididymis at the superior aspect of the testicle. The area is positive to trans-illumination. Testicular ultrasound confirms that this is a single spermatocele located at the head of the epididymis on the right testicle. Patient is reassured that this is a benign cystic type of lesion and no treatment is necessary at this time. He should continue to do TSE and return if he has pain or the lump becomes larger.
Diagnosis: Solitary spermatocele of epididymis
Diagnosis Code(s)
N43.41
Spermatocele of epididymis, single
Urethral Stricture
Urethral strictures result from various causes and present a range of manifestations. Causes of urethral stricture include trauma, an adverse effect or complication from medical treatment, inflammatory or infectious processes, and malignancy. Urethral strictures may also be congenital.
Most urethral strictures are the result of trauma to the perineum, such as traumatic catheter placement or removal or a chronic indwelling Foley catheter. Postprocedural urethral stricture is classified at the end of the code block with other intraoperative and postprocedural complications and disorders of the genitourinary system.
Codes for urethral stricture capture the cause (postinfective, post-traumatic, postprocedural, other specified), gender, and for males, the site of the stricture as the meatus, bulbous urethra, membranous urethra, anterior urethra, overlapping sites, or unspecified site. For postinfective stricture, there are more specific codes for postinfective stricture due to the following organisms: schistosomiasis (B65.-, N29), gonorrhea (A54.01), syphilis (A52.76).
Coding and Documentation Requirements
Identify the cause of urethral stricture:
•Postinfective, NEC
•Postprocedural
•Post-traumatic
•Other specified cause
•Unspecified cause
Identify gender:
•Male
•Female
For males, identify the site of the stricture:
•Anterior urethra
•Bulbous urethra
•Meatus
•Membranous urethra
•Overlapping sites
•Unspecified
For female with post-traumatic stricture, identify cause:
•Due to childbirth
•Other specified trauma
ICD-10-CM Code/Documentation
N35.010
Post-traumatic urethral stricture, male, meatal
N35.011
Post-traumatic bulbous urethral stricture
N35.012
Post-traumatic membranous urethral stricture
N35.013
Post-traumatic anterior urethral stricture
N35.014
Post-traumatic urethral stricture, male, unspecified
N35.016
Post-traumatic urethral stricture, male, overlapping sites
N35.021
Urethral stricture due to childbirth
N35.028
Other post-traumatic urethral stricture, female
N35.111
Postinfective urethral stricture, not elsewhere classified, male, meatal
N35.112
Postinfective bulbous urethral stricture, not elsewhere classified, male
N35.113
Postinfective membranous urethral stricture, not elsewhere classified
N35.114
Postinfective anterior urethral stricture, not elsewhere classified, male
N35.116
Postinfective urethral stricture, not elsewhere classified, male, overlapping sites
N35.119
Postinfective urethral stricture, not elsewhere classified, male, unspecified
N35.12
Postinfective urethral stricture, not elsewhere classified, female
N99.110
Postprocedural urethral stricture, male, meatal
N99.111
Postprocedural bulbous urethral stricture, male
N99.112
Postprocedural membranous urethral stricture, male
N99.113
Postprocedural anterior bulbous urethral stricture, male
N99.114
Postprocedural urethral stricture, male, unspecified
N99.115
Postprocedural fossa navicularis urethral stricture
N99.116
Postprocedural urethral stricture, male, overlapping sites
N99.12
Postprocedural urethral stricture, female
N37
Urethral disorders in diseases classified elsewhere
N35.811
Other urethral stricture, male, meatal
N35.812
Other urethral bulbous stricture, male
N35.813
Other membranous urethral stricture, male
N35.814
Other anterior urethral stricture, male
N35.816
Other urethral stricture, male, overlapping sites
N35.819
Other urethral stricture, male, unspecified site
N35.82
Other urethral stricture, female
N35.911
Unspecified urethral stricture, male, meatal
N35.912
Unspecified bulbous urethral stricture, male
N35.913
Unspecified membranous urethral stricture, male
N35.914
Unspecified anterior urethral stricture, male
N35.916
Unspecified urethral stricture, male overlapping sites
N35.919
Unspecified urethral stricture, male, unspecified site
N35.92
Unspecified urethral stricture, female
Documentation and Coding Example
Patient is a thirty-four-year-old Hispanic female who presents for a second urethral dilatation. This healthy woman delivered her first child vaginally six months ago. The infant was over 10 lbs. with fetal distress which necessitated an emergency delivery using forceps. Patient sustained deep lacerations to the vagina, one of which extended close to the urethra. She was subsequently unable to void post-delivery and was straight cathed once and finally had a Foley placed for 24 hours. She mentioned to her OB at her postpartum checkup that she was having pain and urgency with voiding. Exam showed excellent healing of the vaginal mucosa without evidence of fistula and urine culture was negative. She was referred to urology where cystoscopic exam revealed 1 cm long urethral stricture, most likely due to catheterization following delivery. The stricture was dilated using serial sounds and patient’s urinary symptoms resolved. In the past 3 weeks, she has again noticed urinary urgency and frequency. She came into the office and was seen by the PA who found a PVR of 220 cc and sent a cathed urine specimen to the lab for culture which was negative at 72 hours. Procedure Note: Patient is prepped and draped in lithotomy position. The cystoscope inserted without difficulty through the urethral meatus and almost immediately encountered a urethral stricture which is the same size as previously mentioned. Cystoscope advanced into the bladder which appears normal and the scope removed. The urethra is dilated with serial sounds and cystoscope inserted again to visualize the urethra. Excellent dilatation achieved. Patient tolerated procedure well.
Diagnosis: Urethral stricture, post-catheterization
Diagnosis Code(s)
N99.12
Postprocedural urethral stricture, female
Coding Note(s)
Coding post-operative or postprocedural urethral stricture to the highest level of specificity available requires identification of the patient’s gender. In a male, the anatomical position of the urethral stricture is also required. In females, the cause is reported as post-traumatic due to childbirth or other trauma, postinfective, and postprocedural. Postprocedural stricture has an inclusion term that specifies postcatheterization urethral stricture.
Vaginitis/Vulvovaginitis
Vaginitis describes an inflammation of the vagina while vulvovaginitis is inflammation or infection of the vulva and vagina together. Vulvovaginitis may be due to bacteria, yeast, virus, or other parasites, as well as sexually transmitted infections. Allergens, certain chemicals, and factors such as poor hygiene can also cause the condition. Vaginitis and vulvovaginitis are extremely common conditions with similar presentations, so clear documentation of the patient’s condition, along with documentation of the etiology, is essential for correct code assignment.
Some types of cases are coded elsewhere. For instance, ICD-10-CM excludes cases of candidal, chlamydial, gonococcal, syphilitic, and tuberculous vaginitis/vulvitis/vulvovaginitis from the genitourinary chapter and provides separate classifications within the infectious disease chapter. Vaginitis and vulvovaginitis in other diseases, such as pinworm, requires documentation of the underlying disease first in order to assign the correct codes.
Separate codes for vaginitis and vulvitis are provided, and these conditions are subclassified as acute or subacute/chronic. Careful attention to the inclusions shows that inflammation/infection of both the vulva and the vagina together is coded to vaginitis and the default code for unspecified cases is acute.
Coding and Documentation Requirements
Identify site:
•Vaginitis (includes vaginitis with vulvitis)
•Vulvitis
Specify status:
•Acute
•Chronic (includes subacute)
•In diseases classified elsewhere
For acute and chronic types, use additional code to identify infectious agent.
Note: Vaginitis, vulvitis, and vulvovaginitis in diseases classified elsewhere is classified to subcategory N77.1 and site and status are not an axis of classification. The underlying disease should be coded first with attention to the specific causative types that are excluded and must be reported with a code in Chapter 1.
ICD-10-CM Code/Documentation
N76.0
Acute vaginitis
N76.1
Subacute and chronic vaginitis
N76.2
Acute vulvitis
N76.3
Subacute and chronic vulvitis
N77.1
Vaginitis, vulvitis and vulvovaginitis in diseases classified elsewhere
Documentation and Coding Example
Twenty-year-old African American female presents to Student Health with c/o vaginal discharge, itching x two months, and pain with intercourse x one week. Patient is sexually active with one partner and uses oral contraceptives. Her symptoms began about a week after she returned from summer break. She states she was not sexually active during that time but she suspects her boyfriend was. On examination, the vulva appears mildly red but patient denies any vulvar symptoms. Speculum is inserted with some difficulty into the vagina due to extreme discomfort. The vaginal walls are pink but not erythematous. A frothy whitish-gray discharge adheres to the mucosal lining of the vagina. Sample of discharge placed on wet mount. Cervix is closed and without discharge. Bimanual exam elicits some cervical motion tenderness. The rest of the exam is WNL. Wet mount is positive for clue cells, negative for yeast buds, WBCs, or epithelial cells. Vaginal pH 5.5.
Impression: Bacterial vaginitis.
Plan: Clindamycin 2% cream, insert 1 applicator into vagina at bedtime x 7 days.
Diagnosis: Bacterial vaginitis.
Diagnosis Code(s)
N76.0
Acute vaginitis
B96.89
Other specified bacterial agents as the cause of disease classified elsewhere
Coding Note(s)
Acuity status is an axis of classification for this condition, which classifies bacterial vaginitis as acute vaginitis. Clue cells found on microscopic examination of vaginal wet mount preparations demonstrate bacterial vaginosis as clue cells are vaginal epithelial cells that have bacteria adhering to their surfaces. The code for bacteria, NEC causing disease classified elsewhere, B96.89, is also assigned.
Vesicoureteral Reflux
Vesicoureteral reflux is the abnormal flow of urine back up the ureters and is usually diagnosed in infants and children. Vesicoureteral reflux can be unilateral or bilateral and documentation of laterality is necessary for the most accurate code assignment. Vesicoureteral reflux can damage the kidneys. When this occurs, it is referred to as reflux nephropathy. Coding requires documentation indicating the presence or absence of damage to the kidneys caused by the reflux of urine. Codes for vesicoureteral reflux also capture the presence or absence of hydroureter. Vesicoureteral reflux with reflux nephropathy is not the same as reflux associated pyelonephritis and the two conditions are coded differently, so the two conditions must be clearly differentiated in the documentation.
Coding and Documentation Requirements
Identify the type/presentation of vesicoureteral reflux:
•With reflux nephropathy
–With hydroureter
»Bilateral
»Unilateral
»Unspecified
–Without hydroureter
»Bilateral
»Unilateral
»Unspecified
•Without reflux nephropathy
•Unspecified
ICD-10-CM Code/Documentation
N13.70
Vesicoureteral-reflux, unspecified
N13.71
Vesicoureteral-reflux without reflux nephropathy
N13.721
Vesicoureteral-reflux with reflux nephropathy without hydroureter, unilateral
N13.722
Vesicoureteral-reflux with reflux nephropathy without hydroureter, bilateral
N13.729
Vesicoureteral-reflux with reflux nephropathy without hydroureter, unspecified
N13.731
Vesicoureteral-reflux with reflux nephropathy with hydroureter, unilateral
N13.732
Vesicoureteral-reflux with reflux nephropathy with hydroureter, bilateral
N13.739
Vesicoureteral-reflux with reflux nephropathy with hydroureter, unspecified
Documentation and Coding Example
Ten-year-old Caucasian female presents to Urology Clinic for annual exam. The patient is well known to our practice having been followed since the age of five when she presented with a UTI and subsequent work up revealed vesicoureteral reflux with reflux nephropathy and hydroureter. She had an ultrasound prior to this appointment that shows her condition to be stable, unchanged. Physical exam is unremarkable. Labs are significant for mildly elevated BUN and creatinine. Urine culture showed no growth of bacteria. She will continue to take daily Macrodantin and bring in a monthly clean catch voided urine for culture. RTC in 1 year, sooner if problems arise.
Diagnosis: Vesicoureteral reflux with reflux nephropathy and hydroureter.
Diagnosis Code(s)
N13.739
Vesicoureteral-reflux with reflux nephropathy with hydroureter, unspecified
Coding Note(s)
An unspecified code is assigned because the medical record documentation does not specify whether the patient’s condition was affecting only one kidney or both.
Summary
Maintaining best practices in documentation of genitourinary disorders requires detailed information on the diagnosis and treatment of these conditions. Coders will find that some aspects of coding are streamlined thanks to an increased number of combination codes that identify both the (type of) disorder and its manifestation or status. For example, cystitis is now a combination code which bases the code selection on the type of cystitis and whether the patient has hematuria or not. The urinary section includes subchapters that classify each code into a code family, making it easier for coders to select the correct code. Many conditions affecting bilateral organs require code assignment that includes the side affected, such as ovarian cysts, torsion, prolapse, hernia, and acquired atrophy of ovaries and/or fallopian tubes, and testicular pain; or whether the condition affects only one side or both sides, such as vesicoureteral reflux.
The clinical terminology used to describe genitourinary disorders has been updated from that used previously in order to include advances in medical diagnosis and treatment for conditions. An example of this is erectile dysfunction following radiation therapy, interstitial seed therapy, or prostate ablative therapy. This, in turn, requires an understanding of specific coding terms as well as detailed documentation of the patient’s condition.
Chapter 14 Quiz
1.What information is NOT required to code vesicoureteral reflux to the highest level of specificity?
a.Documentation of the presence/absence of reflux nephropathy
b.Documentation of unilateral vesicoureteral reflux as left or right
c.Documentation of with or without hydroureter
d.Documentation of laterality as unilateral or bilateral
2.Where is postprocedural urethral stricture classified?
a.In the code block for urethral disorders in Chapter 14
b.In a separate code block for intraoperative and postprocedural complications at the end of Chapter 14
c.In Chapter 21 Factors Influencing Health Status and Contact with Health Services
d.With infectious and parasitic diseases in Chapter 1
3.Which of the following statements is true regarding coding hydronephrosis and ureteral calculus?
a.Dual coding is required to report hydronephrosis and ureteral calculus
b.A combination code reports hydronephrosis with ureteral calculus
c.A combination code reports hydronephrosis with ureteral calculus and the side affected
d.Dual coding is required to report hydronephrosis by laterality and ureteral calculus by laterality
4.How is endometriosis classified?
a.By site
b.By etiology
c.By site and laterality
d.By both site and etiology
5.Coding post-traumatic urethral stricture to the highest level of specificity available requires identification of ____________________.
a.The patient’s gender
b.The underlying cause
c.The manifestation
d.All of the above
6.When coding dysmenorrhea, what distinction is made for proper code selection?
a.Site
b.Etiology
c.Type as primary or secondary
d.With or without endometriosis
7.How is Chronic Kidney Disease (CKD) coded?
a.Based on stage of severity
b.Based on type
c.Based on etiology
d.Based on duration of the patient’s chronic condition
8.The physician documents the patient’s diagnosis as “subacute vaginitis.” How is this coded?
a.With the code for acute and subacute vaginitis
b.With the code for chronic vaginitis
c.With the code for subacute and chronic vaginitis
d.With the code for unspecified vaginitis
9.According to the coding and sequencing guidelines for chronic kidney disease in a kidney transplant patient, which of the following is true?
a.A kidney transplant status patient may still have some form of chronic kidney disease
b.The presence of CKD alone does not constitute a transplant complication
c.If the documentation does not clarify whether the CKD constitutes a transplant complication, the provider should be queried
d.All of the above
10.What is the correct coding and sequencing for a patient diagnosed with hematuria and cystitis?
a.A code for the type of cystitis is listed first, followed by a code for the hematuria
b.A code for the hematuria is listed first, followed by the code for cystitis
c.A combination code is assigned that includes the type of cystitis with hematuria
d.A code for the underlying infection is listed first, followed by a code for the cystitis, and a code for the hematuria
Chapter 14 Answers and Rationales
1.What information is NOT required to code vesicoureteral reflux to the highest level of specificity?
b.Documentation of unilateral vesicoureteral reflux as left or right
Rationale: While laterality is an element of coding vesicoureteral reflux, the codes only differentiate the condition as unilateral or bilateral. Unilateral vesicoureteral reflux does not need to be specified as right or left to assign the most specific code. Documentation of the presence or absence of reflux nephropathy and the presence or absence of hydroureter is needed to assign the most specific code.
2.Where is postprocedural urethral stricture classified?
b.In a separate code block for intraoperative and postprocedural complications at the end of Chapter 14
Rationale: ICD-10-CM has a separate code block at the end of Chapter 14 (N99) where all intraoperative and postprocedural complications from treatment of genitourinary disorders are classified.
3.Which of the following statements is true regarding coding hydronephrosis and ureteral calculus?
b.A combination code reports hydronephrosis with ureteral calculus
Rationale: Codes in category N13 Obstructive and reflux uropathy are combination codes which report hydronephrosis with ureteral stricture, with infection, and with renal and ureteral calculous obstruction. Separate codes are not required and laterality is not an axis of classification.
4.How is endometriosis classified?
a.By site
Rationale: Codes in category N80 Endometriosis specify endometriosis of the uterus, ovary, fallopian tube, pelvic peritoneum, rectovaginal septum and vagina, intestine, cutaneous scar, and other sites. Etiology and laterality are not components of coding endometriosis.
5.Coding post-traumatic urethral stricture to the highest level of specificity available requires identification of ____________________.
a.The patient’s gender
Rationale: Identification of the patient’s gender is required for code assignment because subcategory N35.0 Post-traumatic urethral stricture includes further subcategories of codes specifically for male types of post-traumatic urethral stricture and female causes of post-traumatic urethral stricture.
6.When coding dysmenorrhea, what distinction is made for proper code selection?
c.Type as primary or secondary
Rationale: Codes for dysmenorrhea (N94) specify primary type versus secondary type dysmenorrhea.
7.How is Chronic Kidney Disease (CKD) coded?
a.Based on stage of severity
Rationale: Chronic kidney disease is specified as stage 1-5.
8.The physician documents the patient’s diagnosis as “subacute vaginitis.” How is this coded?
c.With the code for subacute and chronic vaginitis
Rationale: Codes in category N76 Other inflammation of vagina and vulva specify cases of vaginitis as either acute (which is the default for unspecified cases), or as subacute and chronic together.
9.According to the coding and sequencing guidelines for chronic kidney disease in a kidney transplant patient, which of the following is true?
d.All of the above
Rationale: According to the ICD-10-CM Official Guidelines for Coding and Reporting Section I.C.14: patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. The guidelines further state that if the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.
10.What is the correct coding and sequencing for a patient diagnosed with hematuria and cystitis?
c.A combination code is assigned that includes the type of cystitis with hematuria
Rationale: In the Tabular List, codes in category N30 for cystitis specify the type of cystitis as with or without hematuria in one combination code, so multiple codes are not needed.