ICD-10 Coding for Blood in the Urine(R31.0, R31.1, R31.21)
Complete ICD-10-CM coding and documentation guide for Blood in the Urine. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Blood in the Urine
R31Primary Range
Hematuria
This range covers all types of hematuria, including gross and microscopic, and is the primary range for coding blood in the urine.
Recurrent and persistent hematuria
This range is used when hematuria is associated with glomerular diseases.
Malignant neoplasm of bladder
This range is relevant when hematuria is a symptom of bladder cancer.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R31.0 | Gross hematuria | Use when there is visible blood in the urine and no specific cause is identified. |
|
| R31.1 | Benign essential microscopic hematuria | Use when hematuria is confirmed microscopically and no other significant pathology is present. |
|
| R31.21 | Asymptomatic microscopic hematuria | Use for screening findings of microscopic hematuria without symptoms. |
|
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 blood in the urine
Essential facts and insights about Blood in the Urine
Primary ICD-10-CM Codes for blood in the urine
Decision Criteria
clinical Criteria
- Visible blood in urine without specific cause
Applicable To
- Visible blood in urine
Excludes
- Hematuria due to known causes (e.g., UTI, kidney stones)
Clinical Validation Requirements
- Visible blood in urine without confirmed etiology
Code-Specific Risks
- Using without confirming gross hematuria through clinical observation.
Coding Notes
- Ensure documentation specifies 'gross hematuria' and includes clinical observations.
R31.1 - Benign essential microscopic hematuria
Use when hematuria is confirmed microscopically and no other significant pathology is present.
Applicable To
- Microscopic hematuria without significant clinical findings
Excludes
- Hematuria with known renal pathology
Clinical Validation Requirements
- Microscopic confirmation with urinalysis showing ≥3 RBC/hpf
Coding Notes
Documentation must confirm microscopic findings and absence of visible blood.
R31.21 - Asymptomatic microscopic hematuria
Use for screening findings of microscopic hematuria without symptoms.
Applicable To
- Microscopic hematuria without symptoms
Excludes
- Symptomatic hematuria
Clinical Validation Requirements
- Urinalysis showing ≥3 RBC/hpf with no symptoms
Coding Notes
Ensure documentation confirms absence of symptoms.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Blood in the Urine to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R31.0.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Increases risk of audit., Financial: Potential for denied claims.
Mitigation Strategy
Use templates to ensure all necessary details are documented.
Impact
Reimbursement: May lead to lower reimbursement., Compliance: Increases risk of audit., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Select the most specific code based on clinical findings (e.g., R31.0 for gross hematuria).
Impact
Using R31.9 without documented efforts to identify cause.
Mitigation Strategy
Ensure documentation supports the most specific code possible.
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 Blood in the Urine, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Blood in the Urine
Use these documentation templates to ensure complete and accurate documentation for Blood in the Urine. These templates include all required elements for proper coding and billing.
Patient with gross hematuria
Specialty: UrologyRequired Elements
- History of present illness
- Physical examination
- Laboratory results
- Imaging findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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