Urology Coding Alert

Remember: You should report N35.028 for females only.

Reporting ICD-10-CM codes can be very challenging since you have to consider many different details from the documentation. Coding urethral strictures is no exception. You must know what type of urethral stricture the patient suffers from and the patient’s gender.

Read on to learn more.

Understand What Urethral Strictures Are

FAQ 1: What is a urethral stricture?

Answer: A urethral stricture is a narrowing of the urethra. It can be caused by injury, instrumentation, infection, and certain non-infectious forms of urethritis. Symptoms can include bloody or dark urine, discharge from the urethra, a strong urge to urinate, frequent urination with a decreased urinary stream, pain in the lower abdomen or pelvic area, and others.

Coding tip: “To accurately code the ICD-10-CM diagnosis of a urethral stricture, one should know the etiology/cause of the stricture, the location of the stricture, and the sex of the patient,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York.

Focus on These Options for Post-Traumatic Urethral Strictures

FAQ 2: What ICD-10-CM codes can I report for a post-traumatic urethral stricture?

Answer: You can look to the following ICD-10-CM codes for post-traumatic urethral strictures:

For males, you would report the following codes:

• N35.010 (Post-traumatic urethral stricture, male, meatal)
• N35.011 (Post-traumatic bulbous urethral stricture)
• N35.012 (Post-traumatic membranous urethral stricture)
• N35.013 (Post-traumatic anterior urethral stricture)
• N35.014 (Post-traumatic urethral stricture, male, unspecified)

For females, you should report the following codes:

• N35.021 (Urethral stricture due to childbirth)
• N35.028 (Other post-traumatic urethral stricture, female)

Don’t miss: As you can see, the above codes are divided by those you should report for males and those you should report for females. You have considerably more code options for males than females.

You must also check your urologist’s medical documentation to see where the stricture is located. For example, if you read that your urologist diagnoses a 45-year-old male patient with a post-traumatic bulbous urethral stricture, you should report N35.011 on your claim.

Patient Has Postinfective Urethral Stricture? Do This

FAQ 3: My urologist documented that the patient has a postinfective urethral stricture. Which ICD-10-CM code should I report?

Answer: You must check your urologist’s medical documentation for some key information before you know which code to report. First, you must know whether the patient is male or female. You must also know where the urethral stricture is located.

For males, you can report postinfective urethral strictures with the following codes:

• N35.111 (Postinfective urethral stricture, not elsewhere classified, male, meatal)
• N35.112 (Postinfective bulbous urethral stricture, not elsewhere classified, male)
• N35.113 (Postinfective membranous urethral stricture, not elsewhere classified, male)
• N35.114 (Postinfective anterior urethral stricture, not elsewhere classified, male)
• N35.119 (Postinfective urethral stricture, not elsewhere classified, male, unspecified)

For females, you have just one code for postinfective urethral strictures: N35.12 (Postinfective urethral stricture, not elsewhere classified, female).

Example: Your urologist documents that a male patient has a postinfective anterior urethral stricture, not elsewhere classified. You should report N35.114 on your claim.

Pinpoint ICD-10-CM Codes for Postprocedural Urethral Stricture

FAQ 4: My urologist documented a postprocedural urethral stricture for a female patient. Which code should I report?

Answer: You should report N99.12 (Postprocedural urethral stricture, female) on your claim.

Don’t miss: The rest of the ICD-10-CM choices for postprocedural urethral strictures are strictly for male patients. They are as follows:

• N99.110 (Postprocedural urethral stricture, male, meatal)
• N99.111 (Postprocedural bulbous urethral stricture, male)
• N99.112 (Postprocedural membranous urethral stricture, male)
• N99.113 (Postprocedural anterior bulbous urethral stricture, male)
• N99.114 (Postprocedural urethral stricture, male, unspecified)
• N99.115 (Postprocedural fossa navicularis urethral stricture)
• N99.116 (Postprocedural urethral stricture, male, overlapping sites)

Report “Other” When You Don’t Have Enough Details

FAQ 5: My urologist did not give me enough details in his documentation to determine what type of urethral stricture the patient has. What ICD-10-CM code should I report in this case?

Answer: If your medical documentation does not include enough information to choose one of the codes discussed from above, you can rely on the following codes:

• N35.811 (Other urethral stricture, male, meatal)
• N35.812 (Other urethral bulbous stricture, male)
• N35.813 (Other membranous urethral stricture, male)
• N35.814 (Other anterior urethral stricture, male)
• N35.816 (Other urethral stricture, male, overlapping sites)
• N35.819 (Other urethral stricture, male, unspecified site)
• N35.82 (Other urethral stricture, female)