Vesicoureteral-reflux with reflux nephropathy with hydroureter, unilateral
ICD-10 N13.731 is a billable code used to indicate a diagnosis of vesicoureteral-reflux with reflux nephropathy with hydroureter, unilateral.
Vesicoureteral reflux (VUR) is a condition where urine flows backward from the bladder into the ureters and potentially into the kidneys. This backward flow can lead to recurrent urinary tract infections (UTIs) and can cause damage to the kidneys, known as reflux nephropathy. In cases where VUR is accompanied by hydroureter, there is dilation of the ureter due to the increased pressure from the refluxing urine. This condition is often unilateral, affecting one side of the urinary tract. Patients may present with symptoms such as flank pain, fever, and signs of infection. Pyelonephritis, an infection of the kidney, can occur as a complication of VUR, leading to interstitial nephritis, which is inflammation of the kidney interstitium. Chronic VUR can also result in hydronephrosis, where the kidney becomes swollen due to the buildup of urine. Management often includes antibiotic prophylaxis to prevent UTIs and may require surgical intervention in severe cases. Understanding the interplay between these conditions is crucial for effective treatment and coding.
Detailed history of urinary symptoms, imaging studies (e.g., ultrasound, VCUG), and treatment plans.
Management of recurrent UTIs, surgical intervention for severe VUR, and monitoring of kidney function.
Ensure documentation reflects the severity of reflux and any associated complications.
Growth and development assessments, family history of urinary issues, and detailed symptomatology.
Evaluation of infants and children with recurrent UTIs and VUR.
Consider age-specific factors and developmental milestones in documentation.
Used in the treatment of VUR to prevent reflux.
Document the indication for the procedure and any pre-operative evaluations.
Urology specialists should ensure detailed operative notes are provided.
Accurate coding of N13.731 is crucial for proper reimbursement, tracking of patient outcomes, and ensuring that the complexity of the patient's condition is reflected in their medical record.
