ICD-10 Coding for Nocturia(R35.1)
Complete ICD-10-CM coding and documentation guide for Nocturia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Nocturia
R30-R39Primary Range
Symptoms and signs involving the urinary system
This range includes codes for symptoms related to urinary conditions, including nocturia.
Key Information: ICD-10 code for nocturia
Essential facts and insights about Nocturia
Primary ICD-10-CM Code for nocturia
Decision Criteria
clinical Criteria
- Presence of nocturnal urination episodes without identified cause
coding Criteria
- No other definitive diagnosis explaining nocturia
Applicable To
- Frequent urination at night
Excludes
- Nocturnal enuresis (R32)
Clinical Validation Requirements
- Documented episodes of urination during the night
- Bladder diary showing nocturnal voiding frequency
Code-Specific Risks
- Incorrectly using as primary code when an underlying condition is identified
Coding Notes
- Ensure nocturia is not coded as primary if an underlying cause is identified.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Frequency of micturition
R35.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Nocturia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R35.1.
Impact
Clinical: May lead to misdiagnosis or inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to insufficient documentation.
Mitigation Strategy
Use structured templates for nocturia documentation., Ensure all nocturnal voids are quantified and timed.
Impact
Reimbursement: May lead to incorrect DRG assignment and affect reimbursement., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Identify and code the underlying condition first, then add R35.1 as secondary.
Impact
Incorrect sequencing of nocturia and underlying conditions.
Mitigation Strategy
Educate coders on proper sequencing rules and use of additional codes.
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 Nocturia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Nocturia
Use these documentation templates to ensure complete and accurate documentation for Nocturia. These templates include all required elements for proper coding and billing.
Urology Consultation for Nocturia
Specialty: UrologyRequired Elements
- Number of nocturnal voids
- Timing of first void
- Bladder diary results
- Underlying conditions
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Nocturia? Ask your questions below.