Congenital vesico-uretero-renal reflux
ICD-10 Q62.7 is a billable code used to indicate a diagnosis of congenital vesico-uretero-renal reflux.
Congenital vesico-uretero-renal reflux (VUR) is a condition characterized by the abnormal flow of urine from the bladder back into the ureters and potentially into the kidneys. This condition is often diagnosed in pediatric patients and can lead to recurrent urinary tract infections (UTIs), kidney damage, and other complications if left untreated. VUR is classified into primary and secondary types, with primary VUR being due to a congenital defect in the ureterovesical junction, while secondary VUR can result from obstruction or other acquired conditions. The severity of VUR is graded from I to V, with higher grades indicating more severe reflux and a greater risk of renal damage. Associated congenital malformations of the urinary system, such as renal agenesis, polycystic kidney disease, bladder exstrophy, and posterior urethral valves, can complicate the clinical picture and management of VUR. Early diagnosis and intervention are crucial to prevent long-term renal impairment and ensure optimal outcomes for affected children.
Pediatric documentation must include growth parameters, developmental milestones, and specific urinary symptoms. Detailed history of urinary tract infections and imaging studies is essential.
Common scenarios include a child presenting with recurrent UTIs, a newborn diagnosed with bladder exstrophy, or a child with a family history of renal anomalies.
Coders should be aware of the age-specific manifestations of VUR and the potential for associated congenital anomalies that may require additional coding.
Genetic documentation should include family history of congenital anomalies, results of genetic testing, and any syndromic associations.
Scenarios may involve genetic counseling for families with a history of congenital urinary tract malformations or syndromes associated with VUR.
Consideration of chromosomal abnormalities that may predispose to urinary tract malformations is crucial for accurate coding.
Used for evaluation of VUR and associated urinary tract anomalies.
Documentation must include indications for cystoscopy and findings.
Pediatric urologists may have specific protocols for cystoscopy in children.
Grading of VUR is crucial as it helps determine the severity of the condition and guides management decisions. Higher grades indicate a greater risk of renal damage and may necessitate surgical intervention or more aggressive monitoring.
