Urology Coding Alert

Reporting diagnosis codes can be tricky because ICD-10-CM offers so many different specific options for most conditions. Neurogenic bladder is no exception. When you submit claims for neurogenic bladder, you must check the medical documentation for the exact type. You should also heed ICD-10’s rules for reporting additional codes.

Read on to learn more.

Rule 1: First, Define Neurogenic Bladder for Clarity

A patient with a neurogenic bladder lacks bladder control because of a brain, spinal cord, or nerve condition.

Nerves and muscles, including the sphincter muscles, work together for the bladder to hold urine until the patient is ready to empty it. However, if an illness or injury damages these nerves, the muscles will not be able to tighten or relax at the appropriate time.

Rule 2: Rely on These ICD-10-CM Options for Neurogenic Bladder

You should turn to the following ICD-10-CM 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.

Don’t miss: The above ICD-10-CM codes indicate “neuropathic bladder.” Neuropathic bladder is the same condition as neurogenic bladder.

Rule 3: Remember to Report Additional Codes for Urinary Incontinence

For all of the neurogenic bladder codes, ICD-10-CM instructs you to use an additional code to identify any associated urinary incontinence with codes 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.

Rule 4: Pinpoint Neurogenic Bladder Symptoms

Neurogenic bladder can cause many different symptoms in patients. These include the following:

• Urinary tract infections (UTIs)
• Kidney stones
• Urinary incontinence (unable to control urine)
• Small urine volume during voiding
• Urinary frequency and urgency
• Leaking urine
• Not feeling that the bladder is full
• Having to urinate constantly

Rule 5: Put it All Together With an Example

Take a look at this example to understand how to report neurogenic bladder.

Example: The urologist performed an open suprapubic tube placement and an open retropubic bladder neck closure. The diagnosis is autonomous neuropathic bladder.

Solution: You should report 51800 (Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck [anterior Y-plasty, vesical fundus resection], any procedure, with or without wedge resection of posterior vesical neck) for the bladder neck closure, followed by 51040 (Cystostomy, cystotomy with drainage) for the suprapubic cystostomy tube. You should report N31.2 as the supporting diagnosis code.