ICD-10 Coding for Right Hydronephrosis(N13.31, N13.2, N13.71)
Complete ICD-10-CM coding and documentation guide for Right Hydronephrosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Hydronephrosis
N13.0-N13.9Primary Range
Obstructive and reflux uropathy
This range includes codes for hydronephrosis and related obstructive uropathies, which are applicable to right hydronephrosis.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N13.31 | Hydroureteronephrosis with ureteral stricture, not elsewhere classified | Use when hydronephrosis is due to a ureteral stricture on the right side. |
|
| N13.2 | Hydronephrosis with renal and ureteral calculous obstruction | Use when hydronephrosis is caused by a stone in the right kidney or ureter. |
|
| N13.71 | Vesicoureteral-reflux with reflux nephropathy, unilateral | Use for unilateral obstructive uropathy affecting the right side. |
|
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 right hydronephrosis
Essential facts and insights about Right Hydronephrosis
Primary ICD-10-CM Codes for right hydronephrosis
Decision Criteria
clinical Criteria
- Presence of ureteral stricture confirmed by imaging
Applicable To
- Right hydroureteronephrosis with ureteral stricture
Excludes
- Congenital ureteral stricture (Q62.1)
Clinical Validation Requirements
- Ureteral narrowing confirmed by imaging
- Documentation of right ureteral stricture causing proximal dilation
Code-Specific Risks
- Avoid using if the stricture location is unspecified.
Coding Notes
- Ensure documentation specifies the stricture's location and laterality.
N13.2 - Hydronephrosis with renal and ureteral calculous obstruction
Use when hydronephrosis is caused by a stone in the right kidney or ureter.
Applicable To
- Right hydronephrosis due to renal or ureteral stone
Excludes
- N20.0 (Kidney stone)
Clinical Validation Requirements
- CT showing right ureteral stone with pelvicaliectasis
- Documentation of stone location and laterality
Coding Notes
Ensure stone location and size are documented.
N13.71 - Vesicoureteral-reflux with reflux nephropathy, unilateral
Use for unilateral obstructive uropathy affecting the right side.
Applicable To
- Right unilateral obstructive uropathy
Excludes
- N13.72 (Bilateral reflux nephropathy)
Clinical Validation Requirements
- Urodynamics showing right-sided bladder outlet obstruction
- Documentation of right-sided obstructive uropathy
Coding Notes
Document the cause of obstruction and specify laterality.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right Hydronephrosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N13.31.
Impact
Clinical: Inaccurate treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always include laterality in the diagnosis., Use templates that prompt for laterality.
Impact
Reimbursement: Unspecified codes may lead to denials., Compliance: Non-compliance with coding guidelines., Data Quality: Decreased accuracy in clinical data.
Mitigation Strategy
Always document the specific cause and laterality to use the most specific code.
Impact
Using unspecified codes can trigger audits.
Mitigation Strategy
Ensure documentation supports specific coding.
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 Right Hydronephrosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Hydronephrosis
Use these documentation templates to ensure complete and accurate documentation for Right Hydronephrosis. These templates include all required elements for proper coding and billing.
Right hydronephrosis due to ureteral stone
Specialty: UrologyRequired Elements
- Chief complaint
- Imaging findings
- Stone size and location
- Plan for treatment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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