Urology Coding Alert
Capture Urethral Injury Cause With Y Code
Question: My urologist saw a patient who had an unintentional urethral injury from self-insertion of a medically necessary urinary catheter. We are trying to find the proper diagnosis code. How would I code “acute urinary retention due to urethral injury from self-catheterization” as noted by the provider? Florida Subscriber Even though the patient placed the catheter for medical reasons and the injury was unintentional, you need to code the issue leading to the retention. Report S37.20XS (Unspecified injury of bladder, sequela). Using the sequela guidelines, you’ll report the complaint (R33.8) treated first, followed by the injury (S37.30XS). Finally, you should report the circumstance of the injury, in this case Y73.3 (Surgical instruments, materials and gastroenterology and urology devices (including sutures) associated with adverse incidents).
Answer: First, report R33.8 (Other retention of urine) for the urinary retention. There is a parenthetical statement under R33.8 that states to code a supplemental code to indicate the causal condition, which is often something like benign prostatic hyperplasia (BPH). However, there isn’t really a causal condition in this case, but rather an injury causing the retention.
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