ICD-10 Coding for Hydroureter(N13.4, N13.2)
Complete ICD-10-CM coding and documentation guide for Hydroureter. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hydroureter
N13.0-N13.9Primary Range
Obstructive and reflux uropathy
This range includes codes for conditions involving obstruction and dilation of the urinary tract, including hydroureter.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N13.4 | Hydroureter | Use when there is ureteral dilation without obstruction or reflux. |
|
| N13.2 | Hydronephrosis with ureteral calculus | Use when a stone is causing ureteral obstruction. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for hydroureter
Essential facts and insights about Hydroureter
Primary ICD-10-CM Codes for hydroureter
Decision Criteria
clinical Criteria
- Ureteral dilation >3mm without obstruction
documentation Criteria
- Specify laterality and measure diameter
Clinical Validation Requirements
- Ureteral diameter >3mm on imaging
- No obstruction or reflux present
Code-Specific Risks
- Ensure laterality is documented to avoid unspecified coding.
Coding Notes
- Document the ureteral diameter and confirm absence of obstruction.
N13.2 - Hydronephrosis with ureteral calculus
Use when a stone is causing ureteral obstruction.
Applicable To
- Obstructive uropathy due to stone
Excludes
- N20.0 (Kidney stone)
Clinical Validation Requirements
- Imaging confirmation of stone causing obstruction
Coding Notes
Ensure stone presence is documented with imaging.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Unilateral hydroureter
N13.71Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Hydroureter to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N13.4.
Impact
Clinical: Impacts treatment decisions., Regulatory: May lead to coding errors., Financial: Affects DRG assignment and reimbursement.
Mitigation Strategy
Always document whether the condition is unilateral or bilateral.
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: Violates Excludes1 note., Data Quality: Leads to inaccurate clinical data.
Mitigation Strategy
Use N13.2 instead if a stone is causing obstruction.
Impact
Failure to document laterality can lead to audit findings.
Mitigation Strategy
Ensure laterality is always documented in clinical notes.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Hydroureter, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hydroureter
Use these documentation templates to ensure complete and accurate documentation for Hydroureter. These templates include all required elements for proper coding and billing.
Urology Consult for Hydroureter
Specialty: UrologyRequired Elements
- Patient history
- Imaging findings
- Lab results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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