Outpatient Facility Coding Alert

Take note: Clinical complications can make all the difference.

Your diagnosis code choices for urine retention under ICD-10 are not much different from what you were accustomed to in ICD-9. You do have expanded options that allow you to code with more specification, however, so it’s time to focus on your provider’s documentation.

Old system: When you still assigned diagnoses based on ICD-9, you had three options:

• 788.20 – Retention of urine, unspecified
• 788.21 – Incomplete bladder emptying
• 788.29 – Other specified retention of urine.

The “other” code 788.29 gets more specific in ICD-10.

ICD 10: The new diagnoses in ICD-10 are straightforward, but do offer a few more details than in years past. They are:

• R33.9 – Retention of urine, unspecified
• R33.8 – Other retention of urine
• R33.0 – Drug induced retention of urine
• R39.14 – Feeling incomplete bladder emptying.

Take note: Don’t miss some important coding guidelines included with the ICD-10. For example:

• R33.8 instructs you to “Code first, if applicable, any causal conditions, such as enlarged prostate (N40.1)”
• R33.0 states that you should “Use additional code for adverse effect, if applicable, to identify drug (T36-T50) with the fifth or sixth character.”
• Category R33 excludes psychogenic retention of urine (F45.8, Other somatoform disorders).

The condition: To understand how ICD-10 codes have delved deeper, it’s important to understand exactly what urine retention is. Clinically speaking, urine retention involves:

• A disorder characterized by accumulation of urine within the bladder because of the inability to urinate
• Inability to empty the urinary bladder
• Incomplete emptying of the bladder.

Watch for any of these details in your provider’s notes to help you pinpoint the most accurate diagnosis.

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