ICD-10 Coding for Bladder Retention(R33.0, R33.8, R33.9, R39.14)
Complete ICD-10-CM coding and documentation guide for Bladder Retention. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bladder Retention
R33Primary Range
Urinary retention
This range includes codes for various types of urinary retention, which is the primary condition being documented.
Other and unspecified symptoms and signs involving the genitourinary system
Includes codes for symptoms related to urinary retention, such as incomplete bladder emptying.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R33.0 | Drug-induced urinary retention | Use when urinary retention is directly attributed to a specific drug. |
|
| R33.8 | Other retention of urine | Use when retention is due to a known cause other than drugs. |
|
| R33.9 | Unspecified retention of urine | Use when no specific cause for retention is identified. |
|
| R39.14 | Incomplete bladder emptying | Use when there is a subjective report of incomplete emptying without objective retention. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for bladder retention
Essential facts and insights about Bladder Retention
Primary ICD-10-CM Codes for bladder retention
Decision Criteria
clinical Criteria
- Documented evidence of drug-induced retention
Applicable To
- Urinary retention due to medication
Excludes
- Urinary retention due to other causes
Clinical Validation Requirements
- Temporal relationship between drug initiation and retention
- Naranjo adverse drug reaction probability score ≥4
Code-Specific Risks
- Failure to document the specific drug causing retention
Coding Notes
- Ensure to document the specific drug and its relation to the retention.
R33.8 - Other retention of urine
Use when retention is due to a known cause other than drugs.
Applicable To
- Retention due to neurogenic bladder
- Postoperative urinary retention
Excludes
- Retention due to drug effects
Clinical Validation Requirements
- Postvoid residual ≥300mL via bladder scan
- Urodynamic confirmation of detrusor underactivity
Coding Notes
Ensure to document the specific cause of retention.
R33.9 - Unspecified retention of urine
Use when no specific cause for retention is identified.
Applicable To
- Retention with no identifiable cause
Excludes
- Retention with known cause
Clinical Validation Requirements
- Retention persists after ruling out obstruction, neurological, and pharmacologic causes
Coding Notes
Document all efforts to identify the cause of retention.
R39.14 - Incomplete bladder emptying
Use when there is a subjective report of incomplete emptying without objective retention.
Applicable To
- Subjective feeling of incomplete emptying
Excludes
- Objective retention of urine
Clinical Validation Requirements
- IPSS score ≥8
- Uroflowmetry Qmax <10mL/sec with interrupted flow
Coding Notes
Ensure subjective symptoms are documented separately from objective findings.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Poisoning by, adverse effect of and underdosing of drugs, medicaments and biological substances
T36-T50Benign prostatic hyperplasia with lower urinary tract symptoms
N40.1Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bladder Retention to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R33.0.
Impact
Clinical: May lead to inappropriate treatment adjustments., Regulatory: Non-compliance with coding standards., Financial: Potential denial of claims due to incomplete coding.
Mitigation Strategy
Always include drug name and dosage in documentation, Review medication history thoroughly
Impact
Reimbursement: May lead to incorrect DRG assignment and affect reimbursement., Compliance: Non-compliance with coding guidelines for specificity., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Use R33.8 or R33.0 with appropriate documentation of the cause.
Impact
Reimbursement: Incorrect sequencing can affect DRG and reimbursement., Compliance: Violates coding sequencing rules., Data Quality: Impacts data integrity and clinical reporting.
Mitigation Strategy
Ensure N40.1 is coded first when BPH is the primary cause.
Impact
High error rates in coding unspecified retention when specific causes are documented.
Mitigation Strategy
Implement thorough documentation reviews and coder training.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Bladder Retention, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bladder Retention
Use these documentation templates to ensure complete and accurate documentation for Bladder Retention. These templates include all required elements for proper coding and billing.
Acute urinary retention in a urology clinic
Specialty: UrologyRequired Elements
- Patient history
- Bladder scan results
- Medication review
- Physical examination findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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