Find information on hyperactive bladder (OAB) diagnosis, including clinical documentation, ICD-10 codes (N31.8, N32.8), medical coding guidelines, and treatment options. Learn about overactive bladder symptoms like urgency, frequency, nocturia, and urge incontinence for accurate healthcare coding and improved patient care. Explore resources for urology coding, bladder control problems, and urinary incontinence management.
Also known as
Other specified disorders of bladder
This code encompasses other bladder disorders not classified elsewhere, including hyperactive bladder.
Urgency of micturition
This relates to an overactive bladder with a strong, sudden need to urinate.
Polyuria
While not always indicative of an overactive bladder, frequent urination can be a symptom.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is there urinary urgency?
Yes
With urinary incontinence?
No
Do not code as Overactive Bladder. Evaluate for other diagnoses.
When to use each related code
| Description |
|---|
| Overactive bladder (OAB) |
| Urge incontinence |
| Interstitial cystitis/bladder pain syndrome |
Miscoding OAB (N31.8) as urge incontinence (N39.4), impacting reimbursement and quality metrics.
Using unspecified codes (R32) without sufficient documentation of hyperactive bladder specifics for accurate severity capture.
Insufficient clinical indicators like frequency, urgency, nocturia documented to support hyperactive bladder diagnosis (N31.8), leading to denials.
Patient presents with symptoms consistent with overactive bladder (OAB), also known as urge incontinence or detrusor overactivity. The patient reports urinary urgency, frequency, and nocturia. Urgency is defined as a sudden, compelling desire to void that is difficult to defer. Frequency is described as voiding eight or more times in a 24-hour period. Nocturia is reported as two or more voids per night. The patient denies dysuria, hematuria, and any history of urinary tract infection. Symptoms impact quality of life, specifically related to sleep disruption and limitations in social activities. Physical examination, including abdominal and pelvic exam, is unremarkable. Differential diagnoses considered include urinary tract infection, interstitial cystitis, and bladder outlet obstruction. Based on patient history and examination findings, the diagnosis of overactive bladder is established. Initial treatment plan includes behavioral modifications such as bladder training, pelvic floor muscle exercises (Kegel exercises), and fluid management. Patient education regarding caffeine and alcohol reduction provided. Follow-up scheduled in four weeks to assess symptom improvement. ICD-10 code N89.1, overactive bladder, is assigned. Medical billing codes for evaluation and management services will be determined based on time spent with the patient and medical decision making complexity.