Find information on ureteral stone with hydronephrosis, including clinical documentation, medical coding, ICD-10 codes N13.2 and N28.89, SNOMED CT concepts, diagnosis codes, treatment options, and healthcare guidelines. Learn about the connection between ureteral stones and hydronephrosis, relevant medical terminology, and best practices for accurate clinical documentation and coding for this diagnosis. This resource provides valuable information for healthcare professionals, medical coders, and clinicians seeking accurate and comprehensive details on ureteral stone with hydronephrosis.
Also known as
Calculus of urinary system
Covers kidney and ureteral stones.
Hydronephrosis
Dilation of the renal pelvis and calyces.
Other difficulty with micturition
May include urinary symptoms associated with stones.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the ureteral stone causing obstruction?
Yes
Which side? Right/Left/Bilateral?
No
Which side? Right/Left/Bilateral?
When to use each related code
Description |
---|
Ureteral Stone with Hydronephrosis |
Ureteral Stone |
Hydronephrosis |
Incorrect coding of laterality (unilateral/bilateral hydronephrosis) can lead to inaccurate reimbursement and data reporting. Specificity is crucial.
Lack of documentation clarifying the obstruction level (upper/mid/lower ureter) may cause coding errors and affect clinical quality metrics.
Failing to document and code hydronephrosis severity (mild/moderate/severe) can impact accurate reflection of patient acuity and resource utilization.
Patient presents with complaints consistent with ureteral colic, including acute flank pain radiating to the groin, hematuria, and nausea. The patient reports the pain as severe and intermittent. On physical examination, costovertebral angle tenderness is noted. Ultrasound imaging reveals the presence of a ureteral stone obstructing the ureter, resulting in hydronephrosis. The stone size is measured at [insert size] mm. Differential diagnosis includes pyelonephritis, renal colic, urinary tract infection, and appendicitis. Assessment confirms a diagnosis of ureteral stone with hydronephrosis. The patient's current pain level is [insert pain scale rating]. Plan includes pain management with [insert medication and dosage], hydration with intravenous fluids, and monitoring for spontaneous stone passage. If the stone does not pass spontaneously, treatment options including lithotripsy, ureteroscopy, or percutaneous nephrolithotomy will be discussed. Patient education provided on ureteral stone prevention, including dietary modifications and increased fluid intake. Follow-up scheduled in [insert timeframe] to reassess symptoms and stone location. ICD-10 code N20.0, Ureteric calculus, is documented. Medical billing codes will be determined based on procedures performed.