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ICD-10 Guide
ICD-10 CodesR39.0

R39.0

Extravasation of urine

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

Code Description

ICD-10 R39.0 is a billable code used to indicate a diagnosis of extravasation of urine.

Key Diagnostic Point:

Extravasation of urine refers to the leakage of urine from the urinary tract into surrounding tissues, which can occur due to various causes such as trauma, obstruction, or surgical complications. Clinically, this condition may present with symptoms such as abdominal pain, swelling, and tenderness in the affected area. Patients may also exhibit signs of infection, including fever and dysuria, depending on the underlying cause. Laboratory findings may reveal elevated white blood cell counts or signs of renal impairment. The condition can lead to serious complications, including abscess formation or sepsis if not promptly diagnosed and treated. Diagnosis typically involves imaging studies such as ultrasound or CT scans to identify the location and extent of the extravasation, as well as laboratory tests to assess renal function and rule out infection. Early recognition and management are crucial to prevent further complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of underlying causes (trauma, obstruction, surgical complications)
  • Potential for misdiagnosis with similar conditions
  • Need for detailed imaging and lab results for accurate diagnosis
  • Variability in clinical presentation among patients

Audit Risk Factors

  • Inadequate documentation of the cause of extravasation
  • Failure to document associated symptoms or complications
  • Misclassification of the condition as a different urinary issue
  • Lack of imaging or lab results to support the diagnosis

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed history of urinary symptoms, imaging results, and lab findings.

Common Clinical Scenarios

Patients presenting with abdominal pain and urinary symptoms after recent surgery.

Billing Considerations

Ensure comprehensive documentation of all symptoms and diagnostic tests performed.

Emergency Medicine

Documentation Requirements

Acute care notes including initial assessment, imaging, and lab results.

Common Clinical Scenarios

Patients presenting with acute abdominal pain and signs of urinary leakage following trauma.

Billing Considerations

Rapid documentation of findings is crucial for accurate coding and treatment.

Coding Guidelines

Inclusion Criteria

Use R39.0 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the diagnosis is supported by clinical documentation, imaging, and lab results
  • Use R39
  • 0 when the extravasation is not classified elsewhere

Exclusion Criteria

Do NOT use R39.0 When
No specific exclusions found.

Related CPT Codes

76700CPT Code

Ultrasound, abdomen, complete

Clinical Scenario

Used to evaluate for extravasation in patients presenting with abdominal pain.

Documentation Requirements

Document the reason for the ultrasound and findings related to extravasation.

Specialty Considerations

Ensure that the imaging report is included in the patient's medical record.

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 extravasation of urine, improving the accuracy of diagnosis and treatment tracking.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like extravasation of urine, improving the accuracy of diagnosis and treatment tracking.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like extravasation of urine, improving the accuracy of diagnosis and treatment tracking.

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 extravasation of urine?

Common causes include trauma, surgical complications, urinary obstruction, and certain medical conditions that affect the urinary tract.