Find information on suprapubic catheter presence, including clinical documentation tips, ICD-10 and SNOMED CT codes, healthcare procedures related to suprapubic catheterization, and medical coding guidelines for accurate reporting. Learn about suprapubic catheter insertion, management, and removal, along with potential complications and relevant medical terminology for precise documentation in electronic health records. This resource provides guidance for healthcare professionals on properly documenting and coding the presence of a suprapubic catheter.
Also known as
Presence of urinary catheter
Indicates the presence of a urinary catheter, including suprapubic types.
Mech compl of urinary cath, init
Covers mechanical complications related to a urinary catheter insertion.
Acute cystitis without hematuria
A common reason for suprapubic catheterization.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the suprapubic catheter indwelling?
Yes
Is there a complication?
No
Do not code. Suprapubic catheter not present.
When to use each related code
| Description |
|---|
| Suprapubic Catheter Present |
| Suprapubic Catheter Complication |
| Suprapubic Catheter Removal |
Coding lacks specificity (indwelling, intermittent) impacting reimbursement and quality metrics. CDI should query for clarification.
Suprapubic catheter diagnosis coded without documented confirmation of placement in medical record, posing audit risk.
Diagnosis lacks documentation supporting medical necessity for suprapubic catheter, increasing compliance risk and denials.
Patient presents with an indwelling suprapubic catheter in situ. The suprapubic catheter insertion site appears clean, dry, and without erythema, edema, or drainage. No signs of infection, such as purulent discharge, tenderness, or surrounding skin breakdown, are noted. The patient reports no pain or discomfort at the catheter insertion site. Urine output is clear and yellow, with volume and characteristics documented. Catheter care, including routine cleansing and dressing changes per facility protocol, is being provided. The indication for suprapubic catheterization was reviewed and documented (e.g., urinary retention, bladder outlet obstruction, neurogenic bladder). The patient's understanding of suprapubic catheter management and potential complications, including catheter-associated urinary tract infection (CAUTI), blockage, and dislodgement, has been assessed and reinforced. Continued monitoring of catheter function, urine output, and insertion site condition is planned. Consideration for suprapubic catheter removal will be based on resolution of the underlying condition necessitating catheterization and patient's overall clinical status. Patient education regarding signs and symptoms of infection and appropriate follow-up care has been provided.