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ICD-10 Guide
ICD-10 CodesR31.1

R31.1

Benign essential microscopic hematuria

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R31.1 is a billable code used to indicate a diagnosis of benign essential microscopic hematuria.

Key Diagnostic Point:

Benign essential microscopic hematuria refers to the presence of red blood cells in the urine that is detected under a microscope, without any associated symptoms or identifiable underlying pathology. This condition is often discovered incidentally during routine urinalysis and is characterized by the absence of significant urinary tract symptoms such as pain, dysuria, or urgency. The hematuria is considered 'benign' when it is not associated with any identifiable disease process, and it typically resolves spontaneously. Common causes of benign essential microscopic hematuria include vigorous exercise, dehydration, and certain medications. It is important to differentiate this condition from other causes of hematuria, which may indicate more serious underlying conditions such as urinary tract infections, kidney stones, or malignancies. Diagnosis is primarily based on urinalysis findings, and further evaluation may be warranted if the hematuria persists or is accompanied by other concerning symptoms.

Code Complexity Analysis

Complexity Rating: Low

Low Complexity

Complexity Factors

  • Lack of associated symptoms
  • Incidental finding during routine tests
  • No need for extensive diagnostic workup
  • Clear definition of benign nature

Audit Risk Factors

  • Inadequate documentation of benign nature
  • Misclassification with other types of hematuria
  • Failure to document the absence of symptoms
  • Inconsistent use of the code across providers

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Document the absence of symptoms and any relevant history that supports the benign nature of the hematuria.

Common Clinical Scenarios

Routine check-ups where hematuria is found incidentally.

Billing Considerations

Ensure that any potential causes of hematuria are ruled out before coding as benign.

Emergency Medicine

Documentation Requirements

Document acute presentation and any immediate interventions or evaluations performed.

Common Clinical Scenarios

Patients presenting with hematuria after exercise or trauma.

Billing Considerations

Consider the need for immediate imaging or further evaluation if there are any concerning symptoms.

Coding Guidelines

Inclusion Criteria

Use R31.1 When
  • Follow official ICD
  • CM coding guidelines, ensuring that the diagnosis is supported by clinical documentation and that the benign nature of the hematuria is clearly stated

Exclusion Criteria

Do NOT use R31.1 When
No specific exclusions found.

Related CPT Codes

81000CPT Code

Urinalysis, automated, with microscopy

Clinical Scenario

Used when performing a urinalysis that reveals microscopic hematuria.

Documentation Requirements

Document the urinalysis results and any relevant patient history.

Specialty Considerations

Ensure that the urinalysis is performed in accordance with laboratory standards.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like benign essential microscopic hematuria, improving the accuracy of patient records and facilitating better clinical decision-making.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like benign essential microscopic hematuria, improving the accuracy of patient records and facilitating better clinical decision-making.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like benign essential microscopic hematuria, improving the accuracy of patient records and facilitating better clinical decision-making.

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 is the difference between benign essential microscopic hematuria and other types of hematuria?

Benign essential microscopic hematuria is characterized by the absence of symptoms and identifiable pathology, while other types of hematuria may be associated with urinary tract infections, kidney stones, or malignancies.