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ICD-10 Guide
ICD-10 CodesQ64.39

Q64.39

Billable

Other atresia and stenosis of urethra and bladder neck

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 Q64.39 is a billable code used to indicate a diagnosis of other atresia and stenosis of urethra and bladder neck.

Key Diagnostic Point:

Atresia and stenosis of the urethra and bladder neck are congenital malformations that can significantly impact urinary function in affected individuals. These conditions may present as complete or partial obstruction, leading to urinary retention, hydronephrosis, and potential renal impairment. Congenital atresia refers to the absence or closure of the urethra or bladder neck, while stenosis indicates a narrowing that restricts urine flow. These malformations can occur in isolation or as part of syndromic presentations, often associated with other urinary tract anomalies such as renal agenesis, bladder exstrophy, or posterior urethral valves. Diagnosis typically involves imaging studies, such as ultrasound or voiding cystourethrogram, and may require surgical intervention to restore normal urinary function. Early identification and management are crucial to prevent complications such as urinary tract infections and renal damage.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of conditions
  • Need for detailed anatomical descriptions in documentation
  • Potential for associated congenital anomalies
  • Differentiation from similar conditions (e.g., urethral stricture)

Audit Risk Factors

  • Inadequate documentation of associated anomalies
  • Failure to specify the type of atresia or stenosis
  • Misclassification of the condition due to similar codes
  • Lack of clarity in surgical intervention details

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Pediatric documentation should include growth parameters, developmental milestones, and specific urinary symptoms. Detailed descriptions of any surgical interventions and follow-up care are essential.

Common Clinical Scenarios

Common scenarios include a newborn presenting with urinary retention, a child with recurrent urinary tract infections, or a patient undergoing surgical correction of bladder neck obstruction.

Billing Considerations

Coders should be aware of the age-specific implications of urinary malformations and the potential for long-term follow-up needs.

Genetics

Documentation Requirements

Genetic documentation should include family history, genetic testing results, and any syndromic associations. Detailed notes on genetic counseling provided to families are also important.

Common Clinical Scenarios

Scenarios may involve a child with a known genetic syndrome presenting with urinary anomalies or a family seeking genetic counseling after a diagnosis of a congenital malformation.

Billing Considerations

Consideration should be given to the potential for chromosomal abnormalities that may accompany urinary tract malformations, necessitating thorough genetic evaluation.

Coding Guidelines

Inclusion Criteria

Use Q64.39 When
  • Coders should adhere to official coding guidelines that emphasize the importance of specificity in congenital conditions
  • Documentation must clearly reflect the nature of the atresia or stenosis, associated anomalies, and any surgical interventions performed

Exclusion Criteria

Do NOT use Q64.39 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

CPT 51700CPT Code

Cystourethrogram

Clinical Scenario

Used to evaluate urinary tract anomalies in patients with suspected atresia or stenosis.

Documentation Requirements

Documentation must include indications for the procedure and findings.

Specialty Considerations

Pediatric urologists often perform these evaluations, requiring specific coding knowledge.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding congenital urinary malformations, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding congenital urinary malformations, improving the accuracy of data collection 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 are the common congenital urinary malformations associated with Q64.39?

Common congenital urinary malformations associated with Q64.39 include renal agenesis, bladder exstrophy, and posterior urethral valves. Each of these conditions can present unique challenges in diagnosis and management, necessitating careful coding and documentation.