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ICD-10 Guide
ICD-10 CodesN36.41

N36.41

Billable

Hypermobility of urethra

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

Code Description

ICD-10 N36.41 is a billable code used to indicate a diagnosis of hypermobility of urethra.

Key Diagnostic Point:

Hypermobility of the urethra refers to an abnormal increase in the mobility of the urethra, which can lead to various urinary symptoms and complications. This condition is often associated with pelvic floor dysfunction and can result in urinary incontinence, urgency, and frequency. The hypermobility may be due to weakened pelvic support structures, which can occur in both men and women, although it is more commonly reported in women, especially those who have had multiple pregnancies or pelvic surgeries. Diagnosis typically involves a thorough clinical evaluation, including a detailed history of urinary symptoms and physical examination. Urodynamic studies may also be utilized to assess bladder function and urethral mobility. Treatment options vary based on the severity of symptoms and may include pelvic floor exercises, behavioral therapies, or surgical interventions to stabilize the urethra. Understanding the implications of urethral hypermobility is crucial for managing associated conditions such as urethritis, urethral stricture, and other urinary system disorders.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and symptoms
  • Need for comprehensive documentation to support diagnosis
  • Potential overlap with other urinary disorders
  • Variations in treatment approaches

Audit Risk Factors

  • Inadequate documentation of symptoms
  • Failure to document associated conditions
  • Lack of urodynamic study results in the medical record
  • Misclassification of hypermobility as a different urinary disorder

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed history of urinary symptoms, results of urodynamic studies, and treatment plans.

Common Clinical Scenarios

Patients presenting with urinary incontinence, pelvic pain, or recurrent urinary tract infections.

Billing Considerations

Ensure that all relevant diagnostic tests are documented to support the diagnosis of hypermobility.

Gynecology

Documentation Requirements

Documentation of obstetric history, pelvic examinations, and any previous surgeries.

Common Clinical Scenarios

Women with a history of childbirth presenting with urinary symptoms.

Billing Considerations

Consideration of pelvic floor rehabilitation as part of the treatment plan.

Coding Guidelines

Inclusion Criteria

Use N36.41 When
  • According to ICD
  • 10 guidelines, N36
  • 41 should be used when hypermobility of the urethra is documented as the primary diagnosis
  • It is important to ensure that the condition is not a secondary manifestation of another underlying disorder

Exclusion Criteria

Do NOT use N36.41 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

51798CPT Code

Urodynamics

Clinical Scenario

Used to evaluate bladder function in patients with suspected urethral hypermobility.

Documentation Requirements

Results of urodynamic studies must be documented in the patient's medical record.

Specialty Considerations

Urologists should ensure that the rationale for testing is clearly stated.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of urethral conditions, improving the accuracy of diagnoses and treatment plans. N36.41 provides a clear classification for hypermobility, which was less defined in ICD-9.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of urethral conditions, improving the accuracy of diagnoses and treatment plans. N36.41 provides a clear classification for hypermobility, which was less defined in ICD-9.

Reimbursement & Billing Impact

reimbursement.

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 symptoms associated with hypermobility of the urethra?

Common symptoms include urinary incontinence, urgency, frequency, and pelvic discomfort. Patients may also report recurrent urinary tract infections.