ICD-10 Logo
ICDxICD-10 Medical Coding
ICD-10 Logo
ICDxICD-10 Medical Coding
ICD 10 CodesDiagnoses
ICD 10 CodesDiagnoses
ICD-10 Logo
ICDxICD-10 Medical Coding

Comprehensive ICD-10-CM code reference with AI-powered search capabilities.

© 2025 ICD Code Compass. All rights reserved.

Browse

  • All Chapters
  • All Categories
  • Diagnoses

Tools

  • AI Code Search
ICD-10-CM codes are maintained by the CDC and CMS. This tool is for reference purposes only.
v1.0.0
ICD-10 Guide
ICD-10 CodesN36.4

N36.4

Billable

Urethral functional and muscular disorders

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/18/2025

Code Description

ICD-10 N36.4 is a billable code used to indicate a diagnosis of urethral functional and muscular disorders.

Key Diagnostic Point:

Urethral functional and muscular disorders encompass a range of conditions affecting the urethra's ability to function properly. This includes urethritis, which is inflammation of the urethra often caused by infections, and urethral stricture, a narrowing of the urethra that can lead to obstructive urinary symptoms. Patients may present with dysuria, urinary frequency, urgency, and in severe cases, urinary retention. These disorders can arise from various etiologies, including trauma, surgical interventions, or inflammatory conditions. Urethral disorders may also be secondary to systemic diseases such as diabetes or neurological conditions that affect bladder function. Accurate diagnosis often requires a combination of patient history, physical examination, and diagnostic imaging or urodynamic studies. Treatment options vary based on the underlying cause and may include medications, catheterization, or surgical interventions to restore normal urethral function.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of underlying causes (infectious, traumatic, inflammatory)
  • Overlap with other urinary system disorders
  • Need for detailed patient history and diagnostic testing
  • Potential for co-existing conditions affecting coding

Audit Risk Factors

  • Inadequate documentation of symptoms and history
  • Failure to specify the type of urethral disorder
  • Misclassification of related urinary disorders
  • Lack of supporting diagnostic tests in the medical record

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed patient history, physical examination findings, and results of diagnostic tests such as cystoscopy or urodynamics.

Common Clinical Scenarios

Patients presenting with urinary obstruction, recurrent urinary tract infections, or post-surgical complications.

Billing Considerations

Ensure clarity in the documentation of the specific urethral disorder and any associated conditions.

Primary Care

Documentation Requirements

Comprehensive history of urinary symptoms, review of systems, and any prior treatments or interventions.

Common Clinical Scenarios

Initial evaluation of dysuria or urinary frequency in patients with no prior urological history.

Billing Considerations

Document any referrals to urology for further evaluation and management.

Coding Guidelines

Inclusion Criteria

Use N36.4 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the specific urethral disorder and any associated conditions
  • Include relevant diagnostic tests and treatments in the medical record to support the coding decision

Exclusion Criteria

Do NOT use N36.4 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

52000CPT Code

Cystoscopy, diagnostic

Clinical Scenario

Used for evaluation of urethral disorders when symptoms are present.

Documentation Requirements

Document indication for cystoscopy and findings.

Specialty Considerations

Urology specialists should ensure thorough documentation of findings and any interventions performed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of urethral disorders, improving the accuracy of data collection and reimbursement processes. N36.4 provides a more detailed classification than previous coding systems, facilitating better patient management and research.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of urethral disorders, improving the accuracy of data collection and reimbursement processes. N36.4 provides a more detailed classification than previous coding systems, facilitating better patient management and research.

Reimbursement & Billing Impact

reimbursement processes. N36.4 provides a more detailed classification than previous coding systems, facilitating better patient management and research.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the common causes of urethral functional and muscular disorders?

Common causes include infections (urethritis), trauma, surgical complications, and systemic diseases such as diabetes that affect nerve function.

How can I differentiate between urethritis and urethral stricture?

Urethritis typically presents with inflammation and infection symptoms, while urethral stricture is characterized by narrowing of the urethra leading to obstructive symptoms.