ICD-10 Coding for Urethral Stenosis(N35.011, N35.113)
Complete ICD-10-CM coding and documentation guide for Urethral Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Urethral Stenosis
N35-N36Primary Range
Urethral stricture and other urethral disorders
This range includes all codes related to urethral strictures, both traumatic and non-traumatic.
Postprocedural disorders of genitourinary system
Includes postprocedural urethral strictures, relevant for coding complications after surgical interventions.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N35.011 | Post-traumatic bulbous urethral stricture, male | Use for male patients with a confirmed bulbous urethral stricture due to trauma. |
|
| N35.113 | Postinfective membranous stricture, male | Use for male patients with a confirmed membranous urethral stricture following infection. |
|
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 stenosis
Essential facts and insights about Urethral Stenosis
Primary ICD-10-CM Codes for urethral stenosis
Decision Criteria
clinical Criteria
- Confirmed bulbous urethral narrowing on imaging
Applicable To
- Stricture due to trauma in the bulbous urethra
Excludes
- Non-traumatic urethral stricture
Clinical Validation Requirements
- Retrograde urethrogram showing bulbous narrowing
- History of trauma
Code-Specific Risks
- Incorrect gender assignment
- Lack of trauma documentation
Coding Notes
- Ensure trauma is documented in the patient's history.
N35.113 - Postinfective membranous stricture, male
Use for male patients with a confirmed membranous urethral stricture following infection.
Applicable To
- Stricture following infection in the membranous urethra
Excludes
- Traumatic urethral stricture
Clinical Validation Requirements
- History of gonococcal urethritis
- Uroflowmetry showing Qmax ≤10 mL/sec
Coding Notes
Ensure infection is documented in the patient's history.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Other difficulty urinating
R39.19Differential 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 Stenosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N35.011.
Impact
Clinical: Leads to inadequate treatment plans., Regulatory: Increases audit risk., Financial: Results in denied claims.
Mitigation Strategy
Always specify stricture location and cause., Use detailed documentation templates.
Impact
Reimbursement: May lead to reduced reimbursement due to lack of specificity., Compliance: Increases risk of audit due to non-specific coding., Data Quality: Decreases data quality and accuracy in patient records.
Mitigation Strategy
Specify the location and cause of the stricture to use a more specific code.
Impact
Using unspecified codes increases audit risk.
Mitigation Strategy
Ensure all documentation includes specific details about the stricture.
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 Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Urethral Stenosis
Use these documentation templates to ensure complete and accurate documentation for Urethral Stenosis. These templates include all required elements for proper coding and billing.
Urology Progress Note
Specialty: UrologyRequired Elements
- Patient history
- Uroflowmetry results
- Imaging findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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