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v1.0.0
ICD-10 Guide
ICD-10 CodesR39.14

R39.14

Feeling of incomplete bladder emptying

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

Code Description

ICD-10 R39.14 is a billable code used to indicate a diagnosis of feeling of incomplete bladder emptying.

Key Diagnostic Point:

The feeling of incomplete bladder emptying, coded as R39.14, refers to a subjective sensation experienced by patients who perceive that their bladder has not fully emptied after urination. This symptom can be associated with various underlying conditions, including urinary tract infections, bladder outlet obstruction, or neurological disorders affecting bladder function. Patients may describe a persistent urge to urinate or a sensation of fullness despite having just voided. This symptom can significantly impact quality of life, leading to increased urinary frequency, nocturia, and potential anxiety regarding urinary control. Clinicians must evaluate this symptom in the context of a comprehensive urinary assessment, including a detailed history, physical examination, and possibly urodynamic studies to determine the underlying cause. Accurate documentation of the patient's experience, associated symptoms, and any relevant medical history is crucial for appropriate coding and management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Subjective nature of the symptom can lead to variability in documentation.
  • Potential overlap with other urinary symptoms complicates coding.
  • Requires thorough clinical evaluation to determine underlying causes.
  • May necessitate additional diagnostic testing for accurate coding.

Audit Risk Factors

  • Inadequate documentation of the patient's subjective experience.
  • Failure to link the symptom to an underlying condition.
  • Misuse of related codes leading to incorrect billing.
  • Lack of clarity in the clinical narrative regarding the symptom's impact.

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including urinary habits, associated symptoms, and any prior treatments.

Common Clinical Scenarios

Patients presenting with chronic urinary symptoms, often in the context of other comorbidities.

Billing Considerations

Consideration of medications that may affect bladder function, such as diuretics or anticholinergics.

Emergency Medicine

Documentation Requirements

Acute presentation documentation, including vital signs, initial assessment, and any immediate interventions.

Common Clinical Scenarios

Patients presenting with acute urinary retention or severe discomfort related to incomplete bladder emptying.

Billing Considerations

Rapid assessment of potential obstructive causes and the need for immediate intervention.

Coding Guidelines

Inclusion Criteria

Use R39.14 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the symptom is documented clearly and linked to any underlying conditions
  • Use additional codes as necessary to capture the full clinical picture

Exclusion Criteria

Do NOT use R39.14 When
No specific exclusions found.

Related CPT Codes

51798CPT Code

Urodynamics, complex

Clinical Scenario

When urodynamic studies are performed to evaluate bladder function.

Documentation Requirements

Document the indication for the study and findings.

Specialty Considerations

Urology specialists often perform these studies.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of symptoms like incomplete bladder emptying, improving the granularity of data for research and treatment outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of symptoms like incomplete bladder emptying, improving the granularity of data for research and treatment outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of symptoms like incomplete bladder emptying, improving the granularity of data for research and treatment outcomes.

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 should be documented to support the use of R39.14?

Document the patient's description of the symptom, any associated urinary issues, and the clinical evaluation performed to assess the symptom.