Find information on left hydronephrosis diagnosis, including clinical documentation, medical coding, ICD-10 codes, SNOMED CT codes, treatment, causes, symptoms, and ultrasound findings. Learn about the pathophysiology of left hydronephrosis and explore resources for healthcare professionals, including coding guidelines and best practices for accurate clinical documentation. This comprehensive guide covers key aspects of left hydronephrosis relevant for physicians, nurses, coders, and other healthcare providers.
Also known as
Hydronephrosis
Unspecified obstruction of the left kidney
Obstructive chronic pyelonephritis
Kidney infection due to blockage, often causing hydronephrosis.
Calculus of kidney and ureter
Kidney stones can obstruct urine flow, leading to hydronephrosis.
Congenital anomalies of kidney
Birth defects affecting kidney structure can cause hydronephrosis.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the hydronephrosis due to obstruction?
Yes
Calculus obstruction?
No
Congenital hydronephrosis?
When to use each related code
| Description |
|---|
| Left kidney swelling due to urine buildup |
| Right kidney swelling due to urine buildup |
| Kidney stones obstructing urine flow |
Missing or incorrect laterality (left, right, bilateral) can lead to inaccurate coding and claims rejection. Ensure proper documentation.
Coding hydronephrosis requires specifying the cause of obstruction if known (e.g., stone, stricture). Unspecified coding may impact reimbursement.
Clinical documentation must support the severity of hydronephrosis (mild, moderate, severe) for accurate coding and quality reporting. Vague descriptions pose a risk.
Q: What are the most effective diagnostic imaging modalities for confirming left hydronephrosis in adults, and what are the key differentiating factors in their application?
A: Ultrasound is often the initial imaging modality for suspected left hydronephrosis due to its non-invasive nature, lack of ionizing radiation, and cost-effectiveness. It can assess renal size, pelvic dilatation, and identify potential obstructing calculi. However, ultrasound may have limitations in visualizing the distal ureter. For a more detailed evaluation of the urinary tract and surrounding structures, CT urography is often preferred. It provides excellent anatomical detail, accurately delineates the level and cause of obstruction (e.g., ureteral stricture, pelvic mass), and helps characterize renal parenchymal changes. MRI urography can be a valuable alternative for patients with contraindications to CT contrast, such as pregnancy or renal insufficiency, offering comparable anatomical detail. Explore how combining ultrasound findings with CT or MRI urography can provide a comprehensive assessment of left hydronephrosis. Consider implementing a standardized imaging protocol based on the suspected underlying etiology and patient characteristics.
Q: How do I differentiate between physiological and pathological left hydronephrosis during pregnancy, and what management strategies are appropriate for each?
A: Physiological left hydronephrosis is relatively common during pregnancy due to hormonal changes (progesterone) and mechanical compression from the gravid uterus, typically more prominent on the right side. It is often asymptomatic and resolves postpartum. Pathological left hydronephrosis, however, requires closer monitoring and potential intervention. Key differentiating factors include the degree of dilatation, presence of symptoms (pain, infection), and evidence of obstruction. Mild dilatation without symptoms is usually managed conservatively with ultrasound follow-up. Significant dilatation, persistent pain, or signs of infection warrant further investigation with CT urography or MRI urography to exclude underlying pathology, such as a calculus or ureteropelvic junction obstruction. Learn more about the appropriate use of prophylactic antibiotics in pregnant patients with hydronephrosis and consider implementing a multidisciplinary approach involving urology and obstetrics for complex cases.
Patient presents with complaints consistent with left hydronephrosis. Symptoms include left flank pain, abdominal pain, urinary tract infection symptoms such as dysuria, frequency, urgency, and possible hematuria. Patient may also report nausea, vomiting, and fever depending on the severity and underlying cause of the obstruction. Physical examination may reveal left costovertebral angle tenderness. Ultrasound of the kidneys and urinary tract reveals dilatation of the left renal collecting system, consistent with left hydronephrosis. Differential diagnosis includes ureteropelvic junction obstruction, ureteral calculus, extrinsic compression, vesicoureteral reflux, and bladder outlet obstruction. Severity of hydronephrosis is graded based on the Society for Fetal Urology grading system. Laboratory tests including urinalysis, complete blood count, and basic metabolic panel are ordered to assess for infection, renal function, and electrolyte imbalances. Further imaging studies such as CT urogram or MRI may be indicated to delineate the cause of the obstruction. Treatment plan will depend on the underlying etiology and severity of the hydronephrosis and may include observation, medical management for pain and infection, or surgical intervention such as ureteral stent placement, pyeloplasty, or nephrostomy tube placement. Patient education provided regarding the diagnosis, treatment options, and potential complications. Follow-up appointments scheduled to monitor renal function and resolution of hydronephrosis.