ICD-10 Coding for Hematuria(R31.0, R31.1, R31.9)
Complete ICD-10-CM coding and documentation guide for Hematuria. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hematuria
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 urine without a confirmed cause. |
|
| R31.1 | Benign essential microscopic hematuria | Use for asymptomatic microscopic hematuria with benign findings. |
|
| R31.9 | Hematuria, unspecified | Use when hematuria is present but the cause is not yet identified. |
|
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 gross hematuria
Essential facts and insights about Hematuria
Primary ICD-10-CM Codes for hematuria
Decision Criteria
clinical Criteria
- Visible blood in urine confirmed by urinalysis
Applicable To
- Visible blood in urine
Excludes
- Hematuria due to acute cystitis (N30.01)
Clinical Validation Requirements
- Urinalysis showing visible blood
- Imaging ruling out stones or masses
Code-Specific Risks
- Confusion with microscopic hematuria
- Incorrect use when a specific cause is identified
Coding Notes
- Ensure documentation specifies 'gross' hematuria.
R31.1 - Benign essential microscopic hematuria
Use for asymptomatic microscopic hematuria with benign findings.
Applicable To
- Microscopic hematuria with benign etiology
Excludes
- Recurrent hematuria with glomerular lesions (N02.1)
Clinical Validation Requirements
- Urinalysis showing >3 RBCs/HPF
- Absence of proteinuria
Coding Notes
Document urinalysis results clearly.
R31.9 - Hematuria, unspecified
Use when hematuria is present but the cause is not yet identified.
Applicable To
- Unspecified hematuria
Excludes
- Specific causes of hematuria
Clinical Validation Requirements
- Initial presentation without specific findings
Coding Notes
Avoid use when a specific cause is identified.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Dysuria
R30.9Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Hematuria to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R31.0.
Impact
Clinical: Leads to misdiagnosis or inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Ensure urinalysis is performed and results are recorded., Train staff on documentation standards.
Impact
Reimbursement: May lead to incorrect DRG assignment and reimbursement issues., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Identify and code the specific cause of hematuria.
Impact
High risk of audits when unspecified codes are overused.
Mitigation Strategy
Ensure specific causes are documented and coded.
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 Hematuria, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hematuria
Use these documentation templates to ensure complete and accurate documentation for Hematuria. These templates include all required elements for proper coding and billing.
Urology Clinic Visit for Hematuria
Specialty: UrologyRequired Elements
- Patient history
- Urinalysis results
- Imaging findings
- Risk factors
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Hematuria? Ask your questions below.