Urology Coding Alert

Question: What is the best diagnosis code to report for incomplete bladder emptying? I’m looking at R33.9, but am not sure if that is correct.

Arkansas Subscriber

Answer: As with many situations in coding, the correct diagnosis depends on the specific details. If the documentation states, “incomplete bladder emptying,” report R33.8 (Other retention of urine). If possible, do not use unspecified diagnoses as many payers will not reimburse for unspecified diagnoses. If, however, the documentation states, “feeling of incomplete bladder emptying,” the better option is R39.14 (Feeling of incomplete bladder emptying).

Tip: Code first any causal condition such as N40.1, (Enlarged prostate with obstruction and LUTS), if applicable.