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R31.9
ICD-10-CM
Hematuria

Understanding hematuria diagnosis, treatment, and documentation is crucial for healthcare professionals. This resource provides information on hematuria ICD-10 codes, medical coding guidelines, clinical documentation improvement for hematuria, microscopic hematuria, gross hematuria, hematuria differential diagnosis, and hematuria symptoms. Learn about proper coding and documentation for accurate reimbursement and improved patient care. Explore resources for healthcare providers, including clinical terminology and best practices related to hematuria in medical records.

Also known as

Blood in urine
Microscopic hematuria
Gross hematuria
+1 more

Diagnosis Snapshot

Key Facts
  • Definition : Blood in the urine, visible or microscopic.
  • Clinical Signs : Pink, red, or brown urine; flank pain; frequent urination; blood clots.
  • Common Settings : Primary care, urgent care, nephrology, urology.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R31.9 Coding
R31

Hematuria

Blood in urine, unspecified cause.

N02-N08

Glomerular diseases

Kidney disorders often associated with hematuria.

N10-N16

Tubulo-interstitial diseases

Kidney diseases that can sometimes cause blood in urine.

N20-N23

Urolithiasis

Kidney stones that may lead to bleeding and hematuria.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the hematuria gross (visible)?

  • Yes

    Traumatic cause?

  • No (Microscopic)

    Traumatic cause?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Blood in urine
Kidney stones
Urinary tract infection

Documentation Best Practices

Documentation Checklist
  • Hematuria diagnosis: Document symptom onset, duration, related factors.
  • Hematuria: Macroscopic or microscopic? Specify color, clots.
  • Document associated pain, dysuria, urinary frequency/urgency.
  • Hematuria: Past urologic history, family history, medications.
  • Hematuria: Physical exam findings, including abdominal/GU exam.

Coding and Audit Risks

Common Risks
  • Unspecified Hematuria

    Coding unspecified hematuria (R31.9) without proper documentation of cause or type creates audit risks and impacts reimbursement.

  • Missed Etiology Codes

    Failure to code underlying conditions causing hematuria (e.g., kidney stones, infection) leads to inaccurate DRG assignment and lost revenue.

  • Microscopic vs. Gross

    Incorrectly coding microscopic (R31.0) versus gross hematuria (R31.7) based on documentation can trigger claim denials and compliance issues.

Mitigation Tips

Best Practices
  • Document hematuria etiology: ICD-10 codes N02, R31, D69.3, etc. CDI crucial.
  • Precisely record source (glomerular, non-glomerular). Improve HCC coding accuracy.
  • Review medications list for causative agents. Supports accurate diagnosis coding.
  • Microscopic vs. macroscopic: Clear documentation impacts treatment, coding (599.70-599.72).
  • Order appropriate imaging/labs. Justifies clinical decisions and coding specificity.

Clinical Decision Support

Checklist
  • Confirm documented hematuria: macroscopic or microscopic?
  • Review urinalysis: RBC presence, morphology, other findings
  • Assess for medication-induced hematuria: anticoagulants, NSAIDs
  • Consider patient history: trauma, infection, family history
  • Order imaging if indicated: CT urogram, renal ultrasound

Reimbursement and Quality Metrics

Impact Summary
  • Hematuria reimbursement hinges on accurate coding (N10-N16, R31) impacting physician revenue.
  • Coding quality affects hematuria diagnosis-related group (DRG) assignment and hospital payments.
  • Precise documentation of hematuria etiology (glomerular, UTI, etc.) is crucial for optimal reimbursement.
  • Hematuria quality metrics track complications like acute kidney injury influencing hospital value-based payments.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Frequently Asked Questions

Common Questions and Answers

Q: What is the most effective differential diagnosis approach for asymptomatic microscopic hematuria in adult patients considering current guidelines?

A: The most effective differential diagnosis approach for asymptomatic microscopic hematuria (AMH) in adults involves a risk-stratified approach based on current guidelines, such as those from the American Urological Association (AUA). For low-risk patients (e.g., younger non-smokers without a family history of urologic malignancy), a repeat urinalysis is often recommended. For intermediate or high-risk patients (e.g., older patients, smokers, history of gross hematuria, occupational exposure to carcinogens), further evaluation with cystoscopy and imaging, such as CT urography or renal ultrasound, is usually indicated. Managing AMH also requires considering other factors like medication use and strenuous exercise. Explore how risk stratification can improve patient outcomes in AMH cases.

Q: How can I distinguish between glomerular and non-glomerular causes of hematuria in a patient presenting with red urine, considering recent research?

A: Distinguishing between glomerular and non-glomerular hematuria requires a comprehensive evaluation considering clinical presentation, laboratory findings, and imaging. Glomerular hematuria often presents with dysmorphic red blood cells (RBCs), red blood cell casts on microscopic examination, and may be accompanied by proteinuria. Non-glomerular hematuria typically involves isomorphic RBCs without casts and less proteinuria. Recent research emphasizes the utility of phase-contrast microscopy for identifying dysmorphic RBCs and the role of novel biomarkers for improved diagnostic accuracy. Further workup might include renal biopsy for suspected glomerular disease or cystoscopy and imaging for suspected non-glomerular causes like urinary tract infections, stones, or malignancy. Consider implementing a standardized protocol for hematuria evaluation in your practice to ensure optimal patient care. Learn more about recent advancements in diagnosing hematuria.

Quick Tips

Practical Coding Tips
  • Code hematuria etiology
  • Document RBC morphology
  • Specify gross vs microscopic
  • Check for pain location
  • Consider SNOMED CT

Documentation Templates

Patient presents with hematuria, defined as blood in the urine.  Chief complaint includes (insert patient's reported symptoms e.g., red urine, pink urine, brown urine, blood clots in urine, painful urination, frequent urination, flank pain, abdominal pain).  Onset of hematuria was (insert timeframe e.g., gradual, sudden) and duration is (insert timeframe e.g., days, weeks, months).  Associated symptoms include (list any relevant symptoms  e.g., dysuria, urinary urgency, urinary frequency, back pain, pelvic pain, fever, chills, weight loss, fatigue).  Patient denies (list pertinent negatives e.g., recent trauma, strenuous exercise, known bleeding disorders, family history of kidney disease).  Physical examination reveals (document relevant findings e.g., vital signs, abdominal tenderness, costovertebral angle tenderness, palpable masses).  Urinalysis shows (document results e.g., positive for blood, presence of red blood cells, proteinuria, leukocyte esterase, nitrites).  Differential diagnosis includes urinary tract infection, kidney stones, bladder cancer, kidney cancer, glomerulonephritis, benign prostatic hyperplasia, trauma, medications.  Plan includes (document ordered tests and treatments e.g., urine culture, microscopic urinalysis, CT scan of abdomen and pelvis, cystoscopy, urine cytology, referral to urology, pain management).  Patient education provided regarding hematuria causes, diagnostic evaluation, and treatment options.  Follow-up scheduled for (insert date and time) to review results and discuss further management.  ICD-10 code (insert appropriate code e.g., R31.9 for hematuria unspecified, N28.89 for other specified disorders of kidney and ureter) and CPT codes (insert appropriate codes for performed procedures e.g., 81000 for urinalysis, 74170 for CT scan of abdomen and pelvis) documented for medical billing and coding purposes.
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