Find comprehensive information on urinary retention diagnosis, including ICD-10 codes (N39.1, R33.8), clinical documentation best practices, and healthcare provider resources. Learn about symptoms, causes, treatments, and medical coding guidelines for acute and chronic urinary retention. This resource supports accurate clinical documentation and appropriate billing for healthcare professionals dealing with urinary retention management.
Also known as
Retention of urine
Inability to completely empty the bladder.
Other disorders of bladder
Includes bladder disorders like neurogenic bladder, not elsewhere classified.
Other difficulties with micturition
Encompasses other specified micturition problems, including post-void dribbling.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the urinary retention acute?
Yes
Is there a postpartum complication?
No
Is it chronic?
When to use each related code
| Description |
|---|
| Urinary Retention: Inability to empty bladder |
| Overflow Incontinence: Leakage from full bladder |
| Neurogenic Bladder: Bladder dysfunction from nerve damage |
Coding urinary retention without specifying acute or chronic leads to inaccurate severity and reimbursement.
Failing to code underlying conditions like BPH or neurologic disorders impacts risk adjustment and quality metrics.
Miscoding postoperative urinary retention as a complication rather than an expected outcome affects quality reporting.
Patient presents with complaints consistent with urinary retention. Symptoms include difficulty initiating urination, weak urinary stream, straining to void, intermittent voiding, feeling of incomplete bladder emptying, and suprapubic discomfort or pressure. The patient reports (frequency of symptoms, e.g., constant, intermittent, worsening, improving) and denies (pertinent negatives, e.g., dysuria, hematuria, fever, flank pain). Physical examination reveals (palpable bladder, distended abdomen, costovertebral angle tenderness or other relevant findings). Post-void residual (PVR) measurement via bladder scan was (volume) mL, indicating significant urinary retention. Differential diagnosis includes benign prostatic hyperplasia (BPH), bladder outlet obstruction, neurogenic bladder, medication side effects, and urethral stricture. Assessment is urinary retention likely secondary to (presumed cause, e.g., BPH, medication). Plan includes (initial catheterization if necessary, medication adjustment if applicable, urology referral for further evaluation, and patient education regarding bladder health, fluid management, and potential complications of urinary retention). ICD-10 code R33.8, urinary retention, unspecified, is assigned. Follow-up scheduled in ( timeframe) to reassess symptoms and PVR.