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Z96.0
ICD-10-CM
Presence of Ureteral Stent

Find information on ureteral stent presence diagnosis, including clinical documentation requirements, medical coding guidelines (ICD-10, CPT), and healthcare resources. Learn about post-ureteroscopy stent care, ureteral stent removal procedures, and potential complications. This resource addresses common patient questions and provides guidance for healthcare professionals on accurately documenting and coding ureteral stent placement, maintenance, and removal.

Also known as

Ureteric Stent Present
Indwelling Ureteral Stent

Diagnosis Snapshot

Key Facts
  • Definition : A ureteral stent is a thin tube placed in the ureter to help urine drain from the kidney to the bladder.
  • Clinical Signs : May be asymptomatic or present with flank pain, hematuria, and urinary frequency.
  • Common Settings : Kidney stones, ureteral stricture, post-urologic surgery.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z96.0 Coding
Z98.81

Presence of other specified implants

Indicates the presence of a ureteral stent, a type of implant.

T83.5XXA

Mech compl of urinary sys dev/proc

Covers mechanical complications of a urinary system device, such as a stent.

N13.89

Other specified urinary disorders

May be used for conditions related to a ureteral stent not classified elsewhere.

Code-Specific Guidance

Decision Tree for

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

Is the ureteral stent present due to a current procedure?

  • Yes

    Is the procedure diagnostic?

  • No

    Is the stent indwelling?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Ureteral stent in place
Displaced ureteral stent
Ureteral stent obstruction

Documentation Best Practices

Documentation Checklist
  • Ureteral stent presence confirmed by imaging (type)
  • Stent placement date and reason documented
  • Stent material and size specified
  • Symptoms related to stent noted
  • Plan for stent removal documented

Coding and Audit Risks

Common Risks
  • Stent Placement Code Missing

    Risk of missing procedure code for initial stent placement, leading to underreporting of services and lost revenue.

  • Stent Type Specificity

    Lack of documentation specifying stent type (e.g., indwelling, nephrostomy) may cause coding errors and compliance issues.

  • Laterality Documentation

    Missing documentation of stent laterality (left, right, bilateral) can lead to inaccurate coding and claim denials.

Mitigation Tips

Best Practices
  • Document stent placement date, type, reason, and planned removal date.
  • Query physician for stent specifics if documentation inadequate for coding.
  • Code stent placement, not just removal. Use ICD-10 Z98.81 for the presence of a stent.
  • Educate physicians on proper stent documentation for accurate reimbursement.
  • Regularly audit stent documentation for CDI and compliance with coding guidelines.

Clinical Decision Support

Checklist
  • Review imaging reports for stent placement confirmation.
  • Check operative notes for stent insertion procedure.
  • Document stent type, size, and location.
  • Assess patient for stent-related symptoms (pain, hematuria).
  • Verify planned stent removal date in the medical record.

Reimbursement and Quality Metrics

Impact Summary
  • Ureteral stent coding accuracy impacts appropriate reimbursement for procedures like stent placement, removal, or exchange.
  • Accurate reporting of ureteral stent presence affects quality metrics related to post-operative complications and readmissions.
  • Proper ureteral stent documentation supports medical necessity for associated imaging and follow-up care, optimizing reimbursement.
  • Correct coding for ureteral stent diagnosis ensures accurate hospital reporting for quality improvement initiatives and resource allocation.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • Code Z96.5 for present stent
  • Verify stent placement date
  • Document stent material type
  • Check for stent complications
  • Query physician if unclear

Documentation Templates

Patient presents with a ureteral stent in situ.  The stent placement was (initial placement date if known, otherwise state reason for unknown date, e.g., placed at outside facility, remote history).  The indication for stent placement was (indication, e.g., nephrolithiasis, ureteral stricture, postoperative urinary diversion).  Patient reports (patient-reported symptoms related to the stent, e.g., asymptomatic, mild flank discomfort, occasional hematuria).  On physical exam, (relevant physical exam findings, e.g., abdomen soft, nontender, no costovertebral angle tenderness).  Review of systems reveals (pertinent positives and negatives related to genitourinary function, e.g., denies dysuria, frequency, urgency).  Current medications include (list medications, especially those affecting coagulation or urinary tract function).  Plan includes (plan for stent management, e.g., scheduled stent removal on (date), monitoring for stent-related complications, patient education regarding stent care and potential complications).  Assessment:  Presence of ureteral stent,  (ICD-10 code Z98.81).  Differential diagnoses included (if applicable, list any alternative explanations for reported symptoms) but presence of stent confirmed by (method of confirmation, e.g., imaging, previous operative report).  Patient education provided regarding signs and symptoms of urinary tract infection, obstruction, and other stent-related complications. Follow-up scheduled as indicated.
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