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v1.0.0
ICD-10 Guide
ICD-10 CodesR39.191

R39.191

Need to immediately re-void

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

Code Description

ICD-10 R39.191 is a billable code used to indicate a diagnosis of need to immediately re-void.

Key Diagnostic Point:

The ICD-10 code R39.191 is used to describe the symptom of an urgent need to void, which may be indicative of various underlying conditions affecting the urinary system. Patients may experience a sudden and intense urge to urinate, often accompanied by discomfort or anxiety. This symptom can arise from a variety of causes, including urinary tract infections (UTIs), bladder irritability, neurological disorders, or prostate issues in men. The urgency may lead to involuntary leakage if the patient is unable to reach a restroom in time. Clinicians should assess the patient's history, including any recent urinary symptoms, medications, and comorbidities, to determine the underlying cause. Laboratory tests such as urinalysis, urine culture, and imaging studies may be warranted to rule out infections or structural abnormalities. Accurate documentation of the patient's symptoms, duration, and associated factors is crucial for proper coding and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying causes
  • Need for thorough patient history and assessment
  • Differentiation from similar urinary symptoms
  • Potential for overlapping diagnoses

Audit Risk Factors

  • Inadequate documentation of urgency and frequency
  • Failure to specify underlying conditions
  • Misuse of related codes leading to upcoding or downcoding
  • Lack of supporting lab results or imaging studies

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including urinary symptoms, comorbidities, and medication review.

Common Clinical Scenarios

Patients presenting with recurrent UTIs, benign prostatic hyperplasia, or overactive bladder.

Billing Considerations

Consideration of chronic conditions that may contribute to urgency, such as diabetes or neurological disorders.

Emergency Medicine

Documentation Requirements

Acute assessment of urinary urgency, including vital signs and immediate lab tests.

Common Clinical Scenarios

Patients presenting with acute urinary retention or severe urinary tract infections.

Billing Considerations

Rapid evaluation of potential complications, such as sepsis or renal impairment.

Coding Guidelines

Inclusion Criteria

Use R39.191 When
  • Follow official ICD
  • 10 coding guidelines, ensuring that the symptom is documented clearly and that any underlying conditions are also coded appropriately
  • Use R39
  • 191 when the urgency to void is the primary concern and not attributable to a more specific diagnosis

Exclusion Criteria

Do NOT use R39.191 When
No specific exclusions found.

Related CPT Codes

51701CPT Code

Bladder catheterization

Clinical Scenario

Used when a patient presents with acute urinary retention and urgency.

Documentation Requirements

Document the reason for catheterization and any associated symptoms.

Specialty Considerations

In emergency settings, rapid assessment and intervention are critical.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of urinary symptoms, improving the ability to capture the nuances of conditions like urgency to void. R39.191 provides a clear designation for this symptom, aiding in better patient management and research.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of urinary symptoms, improving the ability to capture the nuances of conditions like urgency to void. R39.191 provides a clear designation for this symptom, aiding in better patient management and research.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of urinary symptoms, improving the ability to capture the nuances of conditions like urgency to void. R39.191 provides a clear designation for this symptom, aiding in better patient management and research.

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 I document to support the use of R39.191?

Document the patient's reported symptoms, the urgency of the need to void, any associated discomfort, and any relevant medical history or findings that may contribute to the urgency.