Urology Coding Alert

Hint: “Neuropathic bladder” is the same condition as “neurogenic bladder.”

When your urologist treats a neurogenic bladder, you could be risking reimbursement if you don’t know the correct ICD-10-CM codes to report for the different types such as uninhibited, reflex, and flaccid.

Answer the following questions to keep your neurogenic bladder claims in tip-top shape.

Define Neurogenic Bladder

Question 1: What is a neurogenic bladder?

Answer 1: Neurogenic bladder is abnormal bladder function due to a nervous system disease or disorder.

The bladder stores and empties urine via coordinated activity by the central and peripheral nervous system. Several nerves converge at the bladder to control the urinary tract muscles. These include the sphincter muscles that normally form a tight ring around the urethra and keep urine contained until it’s voluntarily released. Damage to those controlling nerves can be caused by a variety of things and can lead to problems such as urinary incontinence or neurogenic bladder.

See What Causes Neurogenic Bladder

Question 2: What are some common causes and symptom of neurogenic bladder?

Answer 2: Common causes of neurogenic bladder include stroke, multiple sclerosis, spina bifida, and traumatic spinal cord injury.

Neurogenic bladder symptoms: Symptoms of neurogenic bladder include urinary tract infections (UTIs), kidney stones, urinary incontinence (unable to control urine), small urine volume during voiding, urinary frequency and urgency, leaking urine, and having to urinate constantly.

Report Codes from Category N31- for Neurogenic Bladder

Question 3: Which ICD-10-CM codes should I report for neurogenic bladder?

Answer 3: You should report the following codes for neurogenic bladder:

• N31.0 (Uninhibited neuropathic bladder, not elsewhere classified)
• N31.1 (Reflex neuropathic bladder, not elsewhere classified)
• N31.2 (Flaccid neuropathic bladder, not elsewhere classified) Note: This code also includes atonic (motor) (sensory) neuropathic bladder, autonomous neuropathic bladder, and nonreflex neuropathic bladder.
• N31.8 (Other neuromuscular dysfunction of bladder)
• N31.9 (Neuromuscular dysfunction of bladder, unspecified). Note: This code also includes neurogenic bladder dysfunction NOS.

Coding tip: The above ICD-10-CM code descriptors indicate “neuropathic bladder.” However, “neuropathic bladder” is the same condition as “neurogenic bladder.”

Don’t miss: For all of the neurogenic bladder codes, ICD-10-CM instructs you to also report an additional code to identify any associated urinary incontinence with options from the following categories:

• N39.3 (Stress incontinence (female) (male)) Note: According to a coding note, you should also report an associate overactive bladder with code N32.81 (Overactive bladder).
• N39.41 (Urge incontinence)
• N39.42 (Incontinence without sensory awareness) Note: This code also includes insensible (urinary) incontinence.
• N39.43 (Post-void dribbling)
• N39.44 (Nocturnal enuresis)
• N39.45 (Continuous leakage)
• N39.46 (Mixed incontinence) Note: This code also includes urge and stress incontinence.

Check Documentation for Important Details

Question 4: My urologist inserted a Foley catheter to treat the patient’s reflex neurogenic bladder. According to the documentation, the insertion was uncomplicated. The patient also had urge incontinence. Which CPT^® and ICD-10-CM codes should I report on my claim?

Answer 4: Report 51702 (Insertion of temporary indwelling bladder catheter; simple (eg, Foley)) as your procedure code. Report N31.1 (Reflex neuropathic bladder, not elsewhere classified) and N39.41 (Urge incontinence) as the ICD-10-CM codes on your claim.

Don’t miss: You can report either 51702 or 51703 (... complicated (eg, altered anatomy, fractured catheter/balloon) for the insertion of an indwelling catheter, such as a Foley catheter. The appropriate code depends on whether the insertion was complicated (51703) or uncomplicated (51702). Your urologist’s documentation will point you toward the correct choice.

Report 51703 when a urologist uses a catheter guide, a council tip catheter, a coude catheter, or injects lubricant down the urethra to the patient to pass a urethral catheter, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.