星空入口

Add all relevant codes linked to the diagnosis to avoid denials.

Coders must be meticulous when dealing with incontinence coding due to the variety of categories and conditions. Each condition has its own specific coding requirements that need to be recognized.

Read on to learn the key terms that can help you consistently choose the correct incontinence codes.

Use These Tips for Neurogenic Bladder Coding

Symptoms of neurogenic bladder include urinary tract infections (UTIs), kidney stones, urinary incontinence (unable to control urine), small urine volume during voiding, urinary frequency and urgency, leaking urine, and having to urinate constantly. Some common causes of neurogenic bladder include stroke, multiple sclerosis, spina bifida, and traumatic spinal cord injury.

You should look to the following ICD-10-CM codes for neurogenic bladder disorders:

• 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.

Coding tip: The above ICD-10-CM code descriptors indicate 鈥渘europathic bladder.鈥� However, 鈥渘europathic bladder鈥� is the same condition as 鈥渘eurogenic bladder.鈥�

Don鈥檛 miss: For all of the neurogenic bladder codes, ICD-10-CM instructs you to also report an additional code to identify any associated urinary incontinence with options 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.

Note These Other Types of Incontinence

Certain treatments suggested by your urologist for patients might be covered under the incontinence diagnosis, but not under the broader diagnosis of overactive bladder. Therefore, it鈥檚 crucial to distinguish between these conditions before selecting the appropriate code. Let鈥檚 compare a few more codes to understand the differences between stress incontinence, urge incontinence, and overactive bladder:

• N39.3 describes a patient鈥檚 inability to retain urine when a stressor occurs. Those stress triggers might include laughing, sneezing, jumping, coughing, or lifting heavy items. This condition is typically more common in females, but the same code applies no matter which gender the urologist treats.
• N39.41
• N32.81 (Overactive bladder) describes a patient鈥檚 sudden, frequent need to urinate. The patient may or may not be incontinent due to this condition, so you should never assume that a patient with overactive bladder is also incontinent.

Do This When Coding for Overactive Bladder

Coding scenario: The urologist鈥檚 notes state the patient has an 鈥渙veractive bladder,鈥� but they don鈥檛 mention incontinence specifically. How should this be coded?

Answer: Because the practitioner鈥檚 notes do not specifically mention the patient is incontinent, you would simply code for the overactive bladder with code N32.81.

Note: Code N32.81 cannot be a substitute for N39.3 and, when relevant, these codes should be used in conjunction. The ICD-10-CM code book includes a note under N39.3, instructing coders to also document an associated overactive bladder if applicable. Hence, a claim for a patient with overactive bladder who also suffers from stress incontinence would contain both codes: N39.3 and N32.81.

Urge incontinence is used to describe a patient鈥檚 sudden urge to urinate, but they do so before they鈥檙e able to reach the toilet. The sudden urge comes on quickly and can happen during the day or night, caused by bladder contractions. This differs from stress incontinence as it is not triggered by a specific event like sneezing or laughing, but by bladder muscle contraction.

Coding for Stress Incontinence

Coding scenario: Patient states they have difficulty making it to the bathroom in time, losing control, dribbling small amounts of urine when laughing, sneezing, or lifting something heavy at home. Physician advised the patient to start pelvic floor exercises to strengthen pelvic floor and to wear protective undergarments in the meantime. Which ICD-10-CM code would you use to code this?

Answer: You would choose N39.3 as the patient鈥檚 symptoms are concurrent with stress incontinence. Pay attention to the code also note reminding you to also code any related or associated overactive bladder the patient may be experiencing with code N32.81.

Pulling it All Together

Coding scenario: The urologist inserted a Foley catheter to treat the patient鈥檚 reflex neurogenic bladder. The procedure was uncomplicated. The patient also experienced urge incontinence. Which CPT^{庐&苍产蝉辫;}and ICD-10-CM codes should appear on the claim?

Answer: You should report 51702 (Insertion of temporary indwelling bladder catheter; simple (eg, Foley)), N31.1, and N39.41 on your claim for the above procedure.

Don鈥檛 miss: You can report either 51702 or 51703 (... complicated (eg, altered anatomy, fractured catheter/balloon) for the insertion of an indwelling catheter, such as a Foley catheter. You would report 51703 when a urologist uses a catheter guide, a council tip catheter, a coude catheter, or injects lubricant down the urethra to the patient to pass a urethral catheter.

The appropriate code depends on whether the insertion was complicated (51703) or uncomplicated (51702). Your urologist鈥檚 documentation will point you toward the correct choice.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC