Post-traumatic urethral stricture, male, overlapping sites
ICD-10 N35.016 is a billable code used to indicate a diagnosis of post-traumatic urethral stricture, male, overlapping sites.
Post-traumatic urethral stricture refers to a narrowing of the urethra that occurs as a result of trauma, which can be due to various causes such as pelvic fractures, surgical interventions, or external injuries. In males, this condition is particularly significant due to the anatomical structure of the male urethra, which is longer and more susceptible to injury. The overlapping sites indicate that the stricture may involve multiple segments of the urethra, complicating both diagnosis and treatment. Symptoms often include difficulty urinating, urinary retention, and recurrent urinary tract infections (UTIs). Diagnosis typically involves imaging studies such as retrograde urethrograms or cystoscopy to visualize the stricture. Treatment options may include urethral dilation, urethrotomy, or surgical reconstruction, depending on the severity and location of the stricture. Accurate coding is essential for proper management and reimbursement, as well as for tracking outcomes in patients with this condition.
Detailed operative reports, imaging studies, and patient history.
Management of post-traumatic urethral strictures following pelvic fractures.
Documentation must clearly indicate the nature of the trauma and the specific sites affected.
Accurate trauma assessments and initial management notes.
Patients presenting with acute urinary retention post-trauma.
Timely documentation of trauma mechanisms is crucial for accurate coding.
Used to evaluate the extent of the stricture.
Operative report detailing findings and interventions.
Urology specialists must document the specific sites of stricture.
Performed to relieve stricture symptoms.
Procedure notes must specify the stricture location.
Ensure to document the patient's response to dilation.
Overlapping sites indicate that the stricture affects multiple segments of the urethra, which can complicate treatment and requires specific documentation to ensure accurate coding.
