Know When to Ask for Urinary Incontinence Clarification
Question: I have an encounter note where the urologist documented the diagnosis as “urinary incontinence.” I’m tempted to use R32 to report the diagnosis, but I also want to query the physician for more information. What would you recommend? Idaho Subscriber Answer: Reporting R32 (Unspecified urinary incontinence) is technically correct based on the documentation you have. However, as a coder, you’ll want to get all the pertinent information to ensure your coding is accurate for the patient’s condition. Therefore, connecting with the provider to further clarify the type of incontinence is the best option. For example, if the patient was experiencing an inability to control the release of urine when they laugh, sneeze, jump, or lift heavy items, the urologist would likely issue a stress incontinence diagnosis. You’d then assign N39.3 (Stress incontinence (female) (male)) to report the condition. The code features a code also note instructing you to report N32.81 (Overactive bladder) to indicate if the stress incontinence is due to an overactive bladder. Mike Shaughnessy, BA, CPC, Development Editor, AAPC
