Question: I’m coding for a patient who has acute pyelonephritis (Proteus) with a right upper ureteral stone, a right mid-ureteral stricture with moderate hydronephrosis and a large blood clot in the right renal pelvis and calices. What are the correct diagnoses?
Pennsylvania Subscriber
Answer: You’ll need to submit several ICD-10 diagnoses to fully report the patient’s condition. These include:
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N10 (Acute pyelonephritis) for the acute pyelonephritis; note that you are directed to include an additional code from B95-B97 to identify the infectious agent. In this case add B96.4 (Proteus [mirabilis] [morganii] as the cause of diseases classified elsewhere)
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N20.1 (Calculus of ureter) for the right upper ureteral stone
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N13.1 (Hydronephrosis with ureteral stricture not classified elsewhere) for the right mid-ureteral stricture and hydronephrosis
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N28.89 (Other specified disorders of kidney and ureter) for the large blood clot in the right renal pelvis and calices.
