Know the difference between ‘urge’ and ‘stress’ incontinence. Reporting correct and accurate diagnosis codes on your incontinence claims is critical to keep denials low and get the pay you deserve. And that means utilizing the most specific ICD-10-CM diagnosis code possible. Another reason: The Centers for Medicaid & Medicaid Services (CMS) mentioned it’s keeping an extra-close eye on certain diagnoses, and one of them just happens to involve incontinence. Context: CMS listed sacral nerve stimulation for urinary incontinence as an “Approved Issue” for its Recovery Audit Contractors (RACs) to review (www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics). Plus, in the past, the Office of Inspector General (OIG) has listed both biofeedback and pelvic floor therapy for incontinence on its Work Plan, and it may do so again in the future. The bottom line is that the government is looking for justification before paying for incontinence services, and the best way you can prove medical necessity is by submitting the most accurate diagnosis codes. Check out a few terminology clues that can help you select the perfect ICD-10-CM diagnosis code for incontinence every time. Stress Incontinence Differs From Overactive Bladder Some of the services providers may recommend for incontinence patients may be covered for diagnoses in the incontinence category but not for the more general “overactive bladder” diagnosis, so you must be able to differentiate these conditions before you choose the right code. Not only can N32.81 not take the place of N39.3, but the codes should be coded together when applicable. A note in the ICD-10-CM code book under N39.3 advises coders to also report an associated overactive bladder when warranted. Therefore, a claim for an overactive bladder patient who has stress incontinence would include: Urge Incontinence vs. Stress Incontinence Another term you might see in the clinician’s documentation is “urge incontinence.” This describes the patient’s sudden urge to urinate, which they do before they’re able to make it to the toilet. It comes on quickly and can happen during day or night, and is caused by the bladder contracting. It’s not triggered by a specific external event as stress incontinence is. To report this diagnosis, you’ll submit: The one major similarity between coding stress incontinence and urge incontinence is that N39.41 also has a note under it indicating that you should “Code also any associated overactive bladder (N32.81).” Therefore, patients with both overactive bladder and urge incontinence would have claims submitted with: Check N39.42 for Incontinence Without Sensory Awareness When the provider documents incontinence without an awareness that urination is about to happen, that’s referred to as “incontinence without sensory awareness.” The patient may not know they need to urinate due to being on certain medications, having dementia/Alzheimer’s, being disabled (such as having a spinal cord injury), or a variety of other issues. If you see this condition documented in the medical record, you’ll report: A note after this code indicates that N39.42 also describes insensible urinary incontinence, so if the provider documents that, you’ll report N39.42. As with the codes above, you’ll report any associated overactive bladder with N32.81.
Understand Post-Void Dribbling In some instances, patients will urinate, but then will expel another small amount of urine immediately thereafter. This condition is more common in males than in females, but it can affect either gender. To report post-void dribbling, you’ll report: If the patient also has overactive bladder, report N32.81 after you list N39.43. Check These Additional Incontinence Diagnoses Although the above codes describe some of the more common incontinence diagnoses most practices see, you may also encounter the following conditions associated with the inability to retain urine: Query the Clinician When Necessary Coders who have been accustomed to reporting the same one or two codes for incontinence may be surprised to see so many options available for this condition. What’s important is to never assume that documentation of “incontinence” refers to one specific code — like stress or urge — just because you’ve seen those diagnoses so often. If the doctor doesn’t provide you with a specific diagnosis and you can’t evaluate the etiology by reading the patient’s chart, you should always query the provider for additional information.