Hematuria
ICD-10 R31 is a billable code used to indicate a diagnosis of hematuria.
Hematuria is defined as the presence of blood in the urine, which can be either gross (visible to the naked eye) or microscopic (detected only through laboratory testing). It is a symptom rather than a diagnosis and can arise from various underlying conditions affecting the urinary tract, kidneys, or bladder. Common causes include urinary tract infections (UTIs), kidney stones, trauma, tumors, and glomerular diseases. The clinical significance of hematuria varies; while it may indicate benign conditions, it can also signal serious pathologies such as malignancies. The diagnostic approach typically involves a thorough patient history, physical examination, urinalysis, and possibly imaging studies or cystoscopy to identify the source of bleeding. Accurate documentation of hematuria is crucial for appropriate coding and management, as it guides further diagnostic and therapeutic interventions.
Detailed patient history, including duration and characteristics of hematuria, associated symptoms, and any relevant medical history.
Patients presenting with hematuria due to UTIs, kidney stones, or glomerulonephritis.
Ensure comprehensive documentation of diagnostic tests performed and their results.
Acute care documentation must include vital signs, initial assessment findings, and any immediate interventions.
Patients with acute hematuria due to trauma or severe infections.
Rapid assessment and documentation of potential life-threatening causes are critical.
Used when evaluating hematuria in a patient.
Document the reason for urinalysis and any findings.
Ensure that the urinalysis is linked to the diagnosis of hematuria.
Gross hematuria is visible to the naked eye, while microscopic hematuria is detected only through laboratory analysis. Both require further evaluation to determine the underlying cause.
