ICD-10 Coding for Urethral Pain(N34.1, R30.0, N39.0)
Complete ICD-10-CM coding and documentation guide for Urethral Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Urethral Pain
N34-N39Primary Range
Diseases of the urinary system
This range includes codes for urethritis, urinary tract infections, and other urinary system disorders that can cause urethral pain.
Symptoms and signs involving the urinary system
This range includes codes for symptoms such as dysuria, which can be associated with urethral pain.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N34.1 | Nonspecific urethritis | Use when urethritis is confirmed as the cause of urethral pain. |
|
| R30.0 | Dysuria | Use when dysuria is present without a confirmed underlying cause. |
|
| N39.0 | Urinary tract infection, site not specified | Use when a UTI is confirmed as the cause of urethral pain. |
|
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 urethral pain
Essential facts and insights about Urethral Pain
Primary ICD-10-CM Codes for urethral pain
Decision Criteria
clinical Criteria
- Presence of urethral discharge and positive swab
Applicable To
- Urethritis due to infection
Excludes
- Urethritis due to sexually transmitted infections
Clinical Validation Requirements
- Purulent discharge
- Positive urethral swab
- Exclusion of STIs
Code-Specific Risks
- Misclassification if STI is present
Coding Notes
- Ensure documentation specifies urethritis as the cause of pain.
R30.0 - Dysuria
Use when dysuria is present without a confirmed underlying cause.
Applicable To
- Painful urination
Excludes
- Painful urination due to confirmed infection
Clinical Validation Requirements
- Localized urethral burning
- Negative urine culture
Coding Notes
Document symptoms clearly to justify use of R30.0.
N39.0 - Urinary tract infection, site not specified
Use when a UTI is confirmed as the cause of urethral pain.
Applicable To
- UTI with dysuria
Excludes
- UTI with specified site
Clinical Validation Requirements
- Positive urine culture
- Pyuria
Coding Notes
Ensure UTI is confirmed with lab results.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Dysuria
R30.0Differential 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 Urethral Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N34.1.
Impact
Clinical: May lead to misdiagnosis or inappropriate treatment., Regulatory: Could result in audit issues due to lack of specificity., Financial: Potential for denied claims due to insufficient documentation.
Mitigation Strategy
Use specific descriptors for symptoms, Ensure thorough clinical evaluation
Impact
Reimbursement: May result in lower reimbursement if specific diagnosis is not coded., Compliance: Could lead to compliance issues if not accurately coded., Data Quality: Impacts data quality and accuracy of medical records.
Mitigation Strategy
Confirm presence of urethritis via exam/labs.
Impact
Risk of coding symptoms without identifying underlying cause.
Mitigation Strategy
Ensure thorough clinical evaluation and documentation.
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 Urethral Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Urethral Pain
Use these documentation templates to ensure complete and accurate documentation for Urethral Pain. These templates include all required elements for proper coding and billing.
Urethral pain with suspected infection
Specialty: UrologyRequired Elements
- Pain location
- Associated symptoms
- Exam findings
- Test results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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