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ICD-10 Guide
ICD-10 CodesN39.42

N39.42

Billable

Incontinence without sensory awareness

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

Code Description

ICD-10 N39.42 is a billable code used to indicate a diagnosis of incontinence without sensory awareness.

Key Diagnostic Point:

Incontinence without sensory awareness refers to a condition where an individual experiences involuntary loss of urine without the conscious awareness of the need to void. This can occur due to various underlying urinary system disorders, including urethritis, urethral strictures, and other urethral disorders. Patients may not recognize the urge to urinate, leading to unexpected leakage. This condition can significantly impact quality of life and may be associated with neurological disorders, bladder dysfunction, or other systemic diseases. Diagnosis typically involves a thorough patient history, physical examination, and possibly urodynamic studies to assess bladder function. Treatment options may include behavioral therapies, pelvic floor exercises, medications, or surgical interventions depending on the underlying cause. Accurate coding is essential for proper management and reimbursement, as it reflects the complexity of the patient's condition and the healthcare services provided.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of underlying causes that can lead to incontinence without sensory awareness.
  • Need for comprehensive patient history and diagnostic testing to determine the cause.
  • Potential overlap with other urinary disorders, complicating accurate coding.
  • Variability in clinical presentation among patients.

Audit Risk Factors

  • Inadequate documentation of the patient's history and symptoms.
  • Failure to specify the underlying cause of incontinence.
  • Misclassification of incontinence type.
  • Lack of supporting evidence for the diagnosis in the medical record.

Specialty Focus

Medical Specialties

Urology

Documentation Requirements

Detailed patient history, physical examination findings, and results from urodynamic studies.

Common Clinical Scenarios

Patients presenting with urinary leakage without awareness, often following surgery or due to neurological conditions.

Billing Considerations

Urologists must ensure that all potential causes are explored and documented to support the diagnosis.

Neurology

Documentation Requirements

Neurological assessments, imaging studies, and evaluations of bladder function.

Common Clinical Scenarios

Patients with neurological disorders such as multiple sclerosis or spinal cord injuries presenting with incontinence.

Billing Considerations

Neurologists should document the relationship between neurological conditions and urinary symptoms.

Coding Guidelines

Inclusion Criteria

Use N39.42 When
  • According to ICD
  • 10 coding guidelines, N39
  • 42 should be used when incontinence occurs without sensory awareness
  • Coders must ensure that the diagnosis is supported by clinical documentation and that any underlying conditions are also coded appropriately

Exclusion Criteria

Do NOT use N39.42 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

51797CPT Code

Urodynamics, complex

Clinical Scenario

Used when assessing bladder function in patients with incontinence.

Documentation Requirements

Complete urodynamic study results and indications for the procedure.

Specialty Considerations

Urologists must ensure that the procedure is justified based on the patient's symptoms.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of urinary incontinence, including the differentiation of incontinence types, which aids in better patient management and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of urinary incontinence, including the differentiation of incontinence types, which aids in better patient management and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 is the difference between N39.41 and N39.42?

N39.41 refers to incontinence with sensory awareness, where the patient can recognize the urge to void, while N39.42 is for incontinence without such awareness, indicating a more complex clinical scenario.