ICD code R30.0 is used to classify and identify the medical condition of painful urination, known as dysuria, for accurate healthcare documentation.
ICD code R30.0 is used to identify the medical condition known as dysuria, which refers to painful or difficult urination. This code is utilized by healthcare providers to document and classify this specific symptom for billing, treatment, and statistical purposes within the healthcare revenue cycle.
1. Painful Urination: The patient experiences discomfort or pain during urination, which is a primary symptom that necessitates the use of this code.
2. Burning Sensation: A burning feeling while urinating is reported by the patient, indicating irritation or inflammation in the urinary tract.
3. Frequent Urination: The patient has an increased urge to urinate more often than usual, which may accompany the primary symptom.
4. Urgency: There is a sudden, strong need to urinate, often with difficulty in delaying urination.
5. Lower Abdominal Pain: The patient may report pain or discomfort in the lower abdomen, which can be associated with urinary issues.
6. Cloudy or Foul-Smelling Urine: Changes in the appearance or odor of urine may be noted, suggesting an underlying issue that aligns with the diagnostic criteria.
7. History of Urinary Tract Infections (UTIs): A patient with a history of UTIs may present with symptoms that align with this code.
8. Absence of Other Diagnosed Conditions: The symptoms are not attributable to other diagnosed conditions such as sexually transmitted infections or kidney stones, which should be ruled out.
9. Physical Examination Findings: Clinical examination may reveal tenderness in the suprapubic region or other signs consistent with urinary discomfort.
10. Laboratory Test Results: Urinalysis or other relevant tests may show signs of infection or inflammation, supporting the use of this code.
For the ICD code R30.0, which pertains to dysuria, the relevant CPT codes that may be applicable for treatment or diagnostic procedures include:
1. 99201-99215: Evaluation and Management (E/M) codes for office or other outpatient visits, depending on the complexity and time spent with the patient.
2. 81000-81003: Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; with or without microscopy.
3. 87086: Culture, bacterial; quantitative colony count, urine.
4. 87088: Culture, bacterial; with isolation and presumptive identification of each isolate, urine.
5. 51798: Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging.
6. 52000: Cystourethroscopy (separate procedure).
These CPT codes are examples of procedures and services that might be used in the evaluation and management of a patient presenting with symptoms associated with ICD code R30.0. The selection of specific CPT codes will depend on the individual patient's clinical situation and the healthcare provider's assessment.
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