ICD-10 Coding for Meatal Stenosis(N35.911, Q64.33)
Complete ICD-10-CM coding and documentation guide for Meatal Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Meatal Stenosis
N35-N36Primary Range
Urethral stricture and other urethral disorders
This range includes codes for urethral strictures, including meatal stenosis, which is a type of urethral stricture.
Congenital malformations of the urinary system
This range includes congenital conditions, such as congenital meatal stenosis.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N35.911 | Urethral stricture, unspecified, male, meatal | Use for acquired meatal stenosis in males, especially post-circumcision. |
|
| Q64.33 | Congenital meatal stenosis | Use for congenital meatal stenosis identified at birth. |
|
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 meatal stenosis
Essential facts and insights about Meatal Stenosis
Primary ICD-10-CM Codes for meatal stenosis
Decision Criteria
clinical Criteria
- Pinpoint meatus with upward urine stream deviation
documentation Criteria
- Absence of congenital anomalies
Applicable To
- Acquired meatal stenosis post-circumcision
Excludes
- Congenital meatal stenosis (Q64.33)
Clinical Validation Requirements
- Physical exam showing pinpoint meatus
- Uroflowmetry with Qmax <5 mL/sec
Code-Specific Risks
- Incorrectly using unspecified codes when meatal stenosis is specified.
Coding Notes
- Ensure documentation specifies the meatal location and post-circumcision context.
Q64.33 - Congenital meatal stenosis
Use for congenital meatal stenosis identified at birth.
Applicable To
- Congenital narrowing of the meatus
Excludes
- Acquired meatal stenosis (N35.911)
Clinical Validation Requirements
- Documented congenital anomaly present at birth
Coding Notes
Ensure congenital nature is clearly documented.
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 Meatal Stenosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N35.911.
Impact
Clinical: May lead to misdiagnosis., Regulatory: Fails to meet documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use detailed templates, Train staff on documentation standards
Impact
Reimbursement: May lead to incorrect DRG assignment., Compliance: Non-compliance with CMS specificity requirements., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Use N35.911 for meatal-specific stenosis instead of unspecified codes.
Impact
Reimbursement: Incorrect billing may lead to denied claims., Compliance: Violates NCCI edits., Data Quality: Affects procedural data accuracy.
Mitigation Strategy
Do not report 53020 with 53450; bundle into 53450.
Impact
Using unspecified codes when specific codes are available.
Mitigation Strategy
Regular training and audits of coding practices.
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 Meatal Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Meatal Stenosis
Use these documentation templates to ensure complete and accurate documentation for Meatal Stenosis. These templates include all required elements for proper coding and billing.
Post-circumcision meatal stenosis in a pediatric patient
Specialty: UrologyRequired Elements
- Meatal appearance
- Uroflowmetry results
- Stream deviation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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