Vesicoureteral-reflux, unspecified
ICD-10 N13.70 is a billable code used to indicate a diagnosis of vesicoureteral-reflux, unspecified.
Vesicoureteral reflux (VUR) is a condition where urine flows backward from the bladder into the ureters and potentially into the kidneys. This abnormal flow can lead to various complications, including urinary tract infections (UTIs), pyelonephritis, and hydronephrosis. In children, VUR is often diagnosed during evaluations for recurrent UTIs, while in adults, it may be identified incidentally during imaging studies for other conditions. The severity of VUR can vary, and it is classified into grades based on the degree of reflux observed. Unspecified VUR indicates that the specific grade or severity has not been documented. The condition can lead to interstitial nephritis due to recurrent infections and inflammation, and in severe cases, it may result in drug-induced nephropathy if nephrotoxic medications are used inappropriately. Management typically involves antibiotic prophylaxis to prevent UTIs, and in some cases, surgical intervention may be necessary to correct the reflux. Accurate coding is essential for appropriate treatment and reimbursement.
Detailed history of urinary tract infections, imaging studies, and any surgical interventions.
Children presenting with recurrent UTIs or renal scarring.
Consideration of age-related factors and developmental milestones in documentation.
Comprehensive evaluation reports, including imaging and surgical notes.
Adults with recurrent UTIs or complications from VUR.
Documentation of any surgical corrections or interventions performed.
Used for evaluation of VUR in patients with recurrent UTIs.
Document indications for the procedure and findings.
Urologists should ensure detailed operative notes are provided.
Vesicoureteral reflux is a condition where urine flows backward from the bladder into the ureters and kidneys, which can lead to infections and kidney damage.
Diagnosis typically involves imaging studies such as ultrasound or voiding cystourethrogram to assess the reflux and its severity.
Treatment may include antibiotic prophylaxis, surgical correction, or observation, depending on the severity of the reflux and associated complications.
