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ICD-10 Guide
ICD-10 CodesR33

R33

Retention of urine

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

Code Description

ICD-10 R33 is a billable code used to indicate a diagnosis of retention of urine.

Key Diagnostic Point:

Retention of urine, classified under ICD-10 code R33, refers to the inability to completely empty the bladder, leading to the accumulation of urine. This condition can manifest as acute or chronic retention and may present with symptoms such as a feeling of fullness in the bladder, discomfort, or pain in the lower abdomen. Patients may also experience urinary urgency or incontinence. The underlying causes can vary widely, including obstruction (e.g., benign prostatic hyperplasia, urethral stricture), neurological disorders (e.g., spinal cord injury, multiple sclerosis), or medication side effects (e.g., anticholinergics). Clinical evaluation often involves a thorough history and physical examination, along with diagnostic tests such as ultrasound or bladder scans to assess post-void residual volume. Laboratory findings may include elevated serum creatinine levels if renal function is compromised due to prolonged retention. Accurate diagnosis and management are crucial to prevent complications such as urinary tract infections or renal impairment.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of underlying causes requiring differential diagnosis
  • Potential for acute vs. chronic classification
  • Need for comprehensive documentation of symptoms and findings
  • Variability in clinical presentation among patients

Audit Risk Factors

  • Inadequate documentation of symptoms leading to retention
  • Failure to specify acute vs. chronic retention
  • Misclassification of retention due to other urinary disorders
  • Lack of supporting diagnostic tests in the medical record

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including onset, duration, and associated symptoms of urinary retention.

Common Clinical Scenarios

Patients presenting with chronic urinary retention due to benign prostatic hyperplasia or neurological conditions.

Billing Considerations

Consideration of comorbid conditions that may contribute to urinary retention, such as diabetes or neurological disorders.

Emergency Medicine

Documentation Requirements

Acute care documentation must include the patient's presenting symptoms, vital signs, and any immediate interventions performed.

Common Clinical Scenarios

Patients presenting with acute urinary retention due to obstruction or medication effects.

Billing Considerations

Rapid assessment and intervention are critical; documentation should reflect the urgency of the situation.

Coding Guidelines

Inclusion Criteria

Use R33 When
  • Follow official ICD
  • 10 coding guidelines, ensuring that the code is used only when urinary retention is the primary diagnosis
  • Document the cause of retention when known, and differentiate between acute and chronic cases

Exclusion Criteria

Do NOT use R33 When
No specific exclusions found.

Related Codes

Child Codes

3 codes
R33.0
Drug induced retention of urine
R33.8
Other retention of urine
R33.9
Retention of urine, unspecified

Related CPT Codes

51798CPT Code

Bladder ultrasound

Clinical Scenario

Used to assess post-void residual volume in patients with urinary retention.

Documentation Requirements

Document the indication for the ultrasound and findings.

Specialty Considerations

Urologists may frequently order this procedure for patients with urinary retention.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of urinary retention, improving the ability to capture the complexity of the condition and its underlying causes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of urinary retention, improving the ability to capture the complexity of the condition and its underlying causes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of urinary retention, improving the ability to capture the complexity of the condition and its underlying causes.

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 acute and chronic urinary retention?

Acute urinary retention is a sudden inability to urinate, often requiring immediate medical attention, while chronic urinary retention is a gradual inability to fully empty the bladder, which may lead to complications over time.