Calculus of lower urinary tract, unspecified
ICD-10 N21.9 is a billable code used to indicate a diagnosis of calculus of lower urinary tract, unspecified.
Calculus of the lower urinary tract refers to the presence of stones or calculi in the bladder or urethra. These stones can form from various substances, including calcium, oxalate, uric acid, and struvite. The formation of these stones, known as urolithiasis, can lead to significant discomfort, urinary obstruction, and potential complications such as urinary tract infections. Symptoms may include hematuria (blood in urine), dysuria (painful urination), and frequent urination. Diagnosis typically involves imaging studies such as ultrasound or CT scans, and laboratory tests to analyze urine composition. Treatment options vary based on the size and location of the stones and may include lithotripsy, which uses shock waves to break up stones, or surgical removal. Dietary modifications, such as increased fluid intake and dietary adjustments to reduce stone-forming substances, are often recommended to prevent recurrence. This code is used when the specific type of calculus is not specified, making it essential for coders to ensure accurate documentation to support the diagnosis.
Detailed imaging reports, treatment plans, and follow-up notes.
Patients presenting with flank pain, hematuria, or urinary obstruction due to stones.
Ensure that all imaging and lab results are documented to support the diagnosis.
Comprehensive patient history, symptom description, and referrals to specialists.
Initial evaluation of patients with urinary symptoms or recurrent urinary tract infections.
Document any dietary recommendations or lifestyle changes suggested to the patient.
Used for patients with calculi in the lower urinary tract requiring non-invasive treatment.
Document the size and location of the stone, as well as the number of sessions required.
Urologists should ensure that all pre-operative evaluations are documented.
Document the patient's symptoms, imaging results, and any treatments provided. Ensure that the clinical context supports the diagnosis of calculus in the lower urinary tract.
