ICD-10 Coding for Dysuria(R30.0, N30.0)
Complete ICD-10-CM coding and documentation guide for Dysuria. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dysuria
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R30.0 | Dysuria | Use when dysuria is present without a confirmed underlying condition. |
|
| N30.0 | Acute cystitis | Use when dysuria is due to confirmed acute cystitis. |
|
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 dysuria
Essential facts and insights about Dysuria
Primary ICD-10-CM Codes for dysuria
Decision Criteria
clinical Criteria
- Dysuria without specific etiology identified
coding Criteria
- No other specific urinary condition diagnosed
Clinical Validation Requirements
- Patient reports painful urination without an identified cause
- Urinalysis pending or negative for infection
Code-Specific Risks
- Overuse when a more specific diagnosis is available
- Incorrect use leading to reimbursement issues
Coding Notes
- Ensure no specific condition is identified before using R30.0.
N30.0 - Acute cystitis
Use when dysuria is due to confirmed acute cystitis.
Applicable To
- Bladder infection
- Cystitis with dysuria
Excludes
- Interstitial cystitis (N30.1)
Clinical Validation Requirements
- Urinalysis showing pyuria and bacteriuria
- Positive urine culture
Coding Notes
Document specific symptoms and confirm with lab results.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
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 Dysuria to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R30.0.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Thorough patient history and examination, Use of diagnostic tests to confirm etiology
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure to code the specific condition causing dysuria, such as cystitis or urethritis.
Impact
Frequent use of R30.0 without supporting documentation.
Mitigation Strategy
Ensure documentation of specific symptoms and lab results.
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 Dysuria, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dysuria
Use these documentation templates to ensure complete and accurate documentation for Dysuria. These templates include all required elements for proper coding and billing.
Initial evaluation of dysuria
Specialty: Primary CareRequired Elements
- Onset and duration of symptoms
- Associated urinary symptoms
- Past medical history
- Physical examination findings
- Laboratory test results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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