Radiology Coding Alert

Watch this: The right code may relate to underlying pathology.

A common yet often ignored diagnosis on radiological claims is urine retention. You can easily miss this diagnosis on ultrasound examinations, unless you are prepared to look for and identify this complaint.

Four Codes Seem To Be Focussed Choice

The following diagnostic choices for urinary retention:

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

You will choose from these codes when there isn’t a defined specific cause of retention of urine. For example, urinary retention is common in elderly in whom a simple cause can be weakness of the muscles in the urinary bladder that cause voiding. In this case, you can simply submit code R33.9.

Note these common drugs that can lead to urine retention (R33.0): Urine retention is a reported adverse events with drugs with anticholinergic activity (e.g. antidepressant and antipsychotic medications), calcium channel blockers, opioids and anesthetics, benzodiazepines, and NSAIDs.

For more on drug induced retention of urine, you may refer to ‘Drug-induced urinary retention: incidence, management and prevention’ at: https://www.ncbi.nlm.nih.gov/pubmed/18422378.

The Cause Is Important In Urinary Retention

However, before you decide to choose a code, you should pay attention to any notes or guidelines associated with a particular diagnosis.

Example 1: A note with R33.8 instructs you to “Code first, if applicable, any causal conditions, such as enlarged prostate (N40.1).

Example 2: Diagnosis 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.”