Hematuria, unspecified
ICD-10 R31.9 is a billable code used to indicate a diagnosis of hematuria, unspecified.
Hematuria, or the presence of blood in urine, can be a significant clinical finding that may indicate various underlying conditions. The term 'unspecified' is used when the cause of hematuria has not been determined or documented. Hematuria can be classified as gross (visible to the naked eye) or microscopic (detected only under a microscope). Common causes include urinary tract infections (UTIs), kidney stones, trauma, tumors, and glomerular diseases. The clinical presentation may vary, with patients reporting symptoms such as flank pain, dysuria, or changes in urinary frequency. Laboratory findings typically include urinalysis, which may reveal red blood cells, protein, or signs of infection. A thorough diagnostic approach is essential, often involving imaging studies like ultrasound or CT scans, and sometimes cystoscopy to visualize the bladder. Accurate documentation of the patient's symptoms, history, and any diagnostic findings is crucial for appropriate coding and management.
Detailed patient history, physical examination findings, and results of urinalysis and imaging studies.
Patients presenting with unexplained hematuria during routine check-ups or following urinary symptoms.
Ensure comprehensive documentation of all diagnostic tests performed and their results to support the diagnosis.
Acute care documentation including triage notes, vital signs, and immediate lab results.
Patients presenting with acute flank pain and hematuria, potentially indicating kidney stones or trauma.
Document the urgency of the situation and any immediate interventions performed.
Used to evaluate hematuria during initial assessment.
Document the results of the urinalysis and any follow-up actions taken.
Ensure that the urinalysis is linked to the diagnosis of hematuria.
Ordered to evaluate for kidney stones or other abnormalities in patients with hematuria.
Document the indication for the ultrasound and the findings.
Link the ultrasound findings to the diagnosis of hematuria.
Use R31.9 when hematuria is documented but the cause is not specified. Ensure that all relevant clinical findings are documented to support this coding.
Common causes include urinary tract infections, kidney stones, trauma, tumors, and glomerular diseases. A thorough evaluation is necessary to determine the underlying cause.
