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v1.0.0
ICD-10 Guide
ICD-10 CodesN36.5

N36.5

Billable

Urethral false passage

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/18/2025

Code Description

ICD-10 N36.5 is a billable code used to indicate a diagnosis of urethral false passage.

Key Diagnostic Point:

Urethral false passage refers to an abnormal channel or pathway that forms in the urethra, typically as a result of trauma, surgical intervention, or the insertion of foreign objects. This condition can lead to complications such as urinary retention, infection, or further urethral stricture. Patients may present with symptoms of dysuria, hematuria, or urinary incontinence. The diagnosis is often confirmed through imaging studies or cystoscopy, which allows for direct visualization of the urethra. Treatment may involve surgical intervention to repair the false passage and restore normal urethral function. It is crucial for healthcare providers to document the specifics of the false passage, including its location and any associated complications, to ensure accurate coding and appropriate management of the condition.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and symptoms among patients
  • Need for precise documentation of the false passage's characteristics
  • Potential for associated conditions like urethritis or stricture
  • Differentiation from other urethral disorders

Audit Risk Factors

  • Inadequate documentation of the cause of the false passage
  • Failure to note associated symptoms or complications
  • Misclassification of the condition as a simple stricture or infection
  • Lack of imaging or procedural documentation to support the diagnosis

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed notes on the patient's history, physical examination findings, and any imaging or procedural results.

Common Clinical Scenarios

Patients presenting with urinary retention, recurrent urinary tract infections, or post-surgical complications.

Billing Considerations

Urologists should ensure that all relevant diagnostic tests are documented to support the diagnosis of a false passage.

Emergency Medicine

Documentation Requirements

Thorough documentation of presenting symptoms, initial assessment, and any immediate interventions performed.

Common Clinical Scenarios

Patients presenting with acute urinary retention or severe dysuria.

Billing Considerations

Emergency physicians should be aware of the potential for false passages in patients with a history of urethral manipulation.

Coding Guidelines

Inclusion Criteria

Use N36.5 When
  • According to ICD
  • 10 guidelines, N36
  • 5 should be used when a false passage is confirmed through clinical evaluation or imaging
  • It is important to document the cause and any associated conditions to ensure accurate coding

Exclusion Criteria

Do NOT use N36.5 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

52310CPT Code

Cystourethroscopy

Clinical Scenario

Used to visualize the urethra and diagnose a false passage.

Documentation Requirements

Document findings from the cystoscopy, including the presence of a false passage.

Specialty Considerations

Urologists should ensure that the procedure is linked to the diagnosis of N36.5.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of urethral disorders, including false passages. This specificity aids in better tracking of patient outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of urethral disorders, including false passages. This specificity aids in better tracking of patient outcomes and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of urethral disorders, including false passages. This specificity aids in better tracking of patient outcomes and resource allocation.

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 are the common causes of urethral false passages?

Common causes include trauma, surgical interventions, and the insertion of foreign objects into the urethra.

How is a urethral false passage diagnosed?

Diagnosis is typically made through imaging studies or cystoscopy, which allows for direct visualization of the urethra.

What are the treatment options for urethral false passages?

Treatment may involve surgical intervention to repair the false passage and restore normal urethral function.