ICD 10 Coding Alert

Answer 1: When a patient has hydronephrosis, something has happened to cause the patient’s kidney to swell because urine isn’t draining normally from the kidney to the bladder. A blockage or obstruction in the urinary tract causes the drainage problem.

Look to Section N

Question 2: My urologist has documented a case of hydronephrosis. Which ICD-10-CM codes should I look to for this diagnosis?

Answer 2: You should look to the following codes for hydronephrosis:

• N13.0 (Hydronephrosis with ureteropelvic junction obstruction). Note: This code also includes hydronephrosis due to acquired occlusion of the ureteropelvic junction.
• N13.1 (Hydronephrosis with ureteral stricture, not elsewhere classified)
• N13.2 (Hydronephrosis with renal and ureteral calculous obstruction). Note: You should report this code if the patient has hydronephrosis with a renal and/or ureteral calculous obstruction.
• N13.30 (Unspecified hydronephrosis)
• N13.39 (Other hydronephrosis)

Caution: In the ICD-10 manual the word “and” in the definition of a diagnostic term means “and” or “or”; so that diagnosis N13.2 above may indicate hydronephrosis secondary to a renal calculus, or a ureteral calculus, or both a renal and ureteral calculus, causing the obstruction and hydronephrosis.

Be Careful When Coding Infection

Question 3: The patient has hydronephrosis with an infection. Which code should I look to?

Answer 3: You should look to N13.6 (Pyonephrosis) when a patient has hydronephrosis with an infection, including obstruction or stricture with infection.

If you look in the ICD-10-CM Coding Manual, you will see a coding note, which informs you that code N13.6 covers conditions in categories N13.0-N13.5 (Crossing vessel and stricture of ureter without hydronephrosis) with infection. Code N13.5 also includes obstructive uropathy with infection.

Don’t miss: If you report code N13.6, you should also use an additional code from categories B95- (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere) through B97- (Viral agents as the cause of diseases classified elsewhere) to identify the infectious agent, if possible.

Don’t Miss the Signs and Symptoms

Question 4: What are some symptoms of hydronephrosis?

Answer 4: Mild — or early — symptoms of hydronephrosis can include more frequent urination and an increased urge to urinate. More severe symptoms if the condition is left untreated can include nausea, vomiting, fever, pain in the abdomen or flank, pain when urinating, and incomplete voiding.

Patient Has Congenital Hydronephrosis? Report This Dx Code

Question 5: The patient has congenital hydronephrosis. Which ICD-10-CM code should I report for that condition?

Answer 5: You should report Q62.0 (Congenital hydronephrosis) for congenital hydronephrosis.

Press for Specific Documentation

Question 6: What is a documentation tip that can help make my hydronephrosis ICD-10-CM coding go smoothly?

Answer 6: You must double-check the documentation and make sure that your urologist is documenting the type of hydronephrosis the patient has as well as whether there are infections, stones, or strictures associated with the hydronephrosis.

“The more specific the proper ICD-10-CM code, the more accurate the coding and reimbursement will be,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.