ICD-10 Coding for Blood in Urine(R31.0, R31.21, R31.9)
Complete ICD-10-CM coding and documentation guide for Blood in 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 Urine
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 without a confirmed etiology. |
|
| R31.21 | Asymptomatic microscopic hematuria | Use when microscopic hematuria is confirmed by lab tests and is asymptomatic. |
|
| R31.9 | Unspecified hematuria | Use only if documentation lacks details and no specific findings are available. |
|
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 urine
Essential facts and insights about Blood in Urine
Primary ICD-10-CM Codes for blood in urine
Decision Criteria
clinical Criteria
- Visible blood in urine confirmed by urinalysis
Applicable To
- Visible blood in urine
Excludes
- Hematuria due to known causes like UTI or stones
Clinical Validation Requirements
- Visible blood in urine
- Urinalysis showing >100 RBCs/HPF
Code-Specific Risks
- Incorrect sequencing if a definitive diagnosis is present
Coding Notes
- Sequence after a definitive diagnosis if hematuria is a symptom.
R31.21 - Asymptomatic microscopic hematuria
Use when microscopic hematuria is confirmed by lab tests and is asymptomatic.
Applicable To
- Microscopic hematuria confirmed by >3 RBCs/HPF
Excludes
- Hematuria due to UTI or stones
Clinical Validation Requirements
- >3 RBCs/HPF on two specimens
Coding Notes
Ensure documentation includes RBC count and symptom status.
R31.9 - Unspecified hematuria
Use only if documentation lacks details and no specific findings are available.
Excludes
- Specific types of hematuria
Clinical Validation Requirements
- Lack of specific findings
Coding Notes
Avoid using if specific findings are documented.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Blood in 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 misdiagnosis or inappropriate treatment., Regulatory: Increases risk of audit failure., Financial: Potential for denied claims due to lack of specificity.
Mitigation Strategy
Always document specific findings such as RBC count., Use templates to ensure comprehensive documentation.
Impact
Reimbursement: May lead to lower reimbursement due to lack of specificity., Compliance: Increases audit risk., Data Quality: Decreases data quality by using unspecified codes.
Mitigation Strategy
Require documentation of microscopy results and symptom status.
Impact
Using R31.9 when more specific codes are applicable.
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 Urine, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Blood in Urine
Use these documentation templates to ensure complete and accurate documentation for Blood in Urine. These templates include all required elements for proper coding and billing.
Urology Clinic Note
Specialty: UrologyRequired Elements
- History of Present Illness
- Laboratory Results
- Imaging Studies
- Assessment and Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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