Urethral discharge, unspecified
ICD-10 R36.9 is a billable code used to indicate a diagnosis of urethral discharge, unspecified.
Urethral discharge refers to the abnormal secretion from the urethra, which can be a symptom of various underlying conditions. This discharge can vary in color, consistency, and odor, and may be accompanied by other symptoms such as dysuria (painful urination), urgency, or frequency of urination. The discharge may be purulent, serous, or mucoid, and its characteristics can provide clues to the underlying etiology. Common causes of urethral discharge include sexually transmitted infections (STIs) such as gonorrhea and chlamydia, urinary tract infections (UTIs), and non-infectious causes like urethritis due to irritation or trauma. In many cases, the specific cause of the discharge may not be immediately identifiable, leading to the use of the unspecified code R36.9. Accurate diagnosis often requires a thorough clinical history, physical examination, and laboratory testing, including urinalysis and cultures, to identify pathogens or other abnormalities. Given the potential for serious underlying conditions, timely and appropriate evaluation is crucial.
Detailed patient history, including sexual history, urinary symptoms, and any prior treatments.
Patients presenting with urethral discharge and dysuria, requiring evaluation for STIs or UTIs.
Consider the need for follow-up testing and monitoring for recurrent symptoms.
Acute care documentation including vital signs, presenting symptoms, and immediate lab results.
Patients with acute onset of urethral discharge and severe pain, requiring rapid assessment and treatment.
Ensure documentation reflects urgency and any immediate interventions performed.
Used when a culture is performed to identify the cause of urethral discharge.
Document the reason for the culture and any relevant clinical findings.
Ensure that the culture is linked to the diagnosis of urethral discharge.
R36.9 should be used when a patient presents with urethral discharge, and the specific cause is not identified or documented. It is important to ensure that all relevant clinical findings are documented to support the use of this code.
