ICD Code R31.9

ICD code R31.9 is used to classify and document cases of hematuria, which is the presence of blood in the urine, when the specific cause or type is not specified. This code is typically used when a healthcare provider identifies blood in a patient's urine but does not have enough information to determine the exact underlying cause or when the cause is not documented in the patient's medical record.

1. Presence of Blood in Urine: The primary criterion for using this code is the detection of blood in the urine, which may be visible to the naked eye or identified through laboratory testing.

2. Absence of Specific Diagnosis: Use this code when the presence of blood in the urine is confirmed, but a specific underlying cause has not been determined or documented.

3. Initial Evaluation: Apply this code during the initial evaluation phase when hematuria is noted, and further diagnostic workup is pending to identify the cause.

4. Non-Specific Symptoms: When the patient presents with non-specific symptoms such as abdominal pain, urinary frequency, or dysuria, and hematuria is identified without a clear etiology.

5. Follow-Up Visits: Utilize this code in follow-up visits when hematuria persists, and a definitive diagnosis has not yet been established despite ongoing investigations.

6. Screening and Routine Examinations: In cases where hematuria is discovered incidentally during routine screenings or examinations, and no specific diagnosis is immediately apparent.

7. Documentation of Unspecified Hematuria: When documenting medical records, use this code to indicate the presence of hematuria when the cause remains unspecified, ensuring accurate record-keeping and billing.

For the ICD code R31.9 (Hematuria, unspecified), the relevant CPT codes that may be applicable for diagnostic and treatment procedures include:

1. 81001 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy.

2. 81002 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy.

3. 81003 - Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy.

4. 81015 - Urinalysis; microscopic only.

5. 81025 - Urine pregnancy test, by visual color comparison methods.

6. 84156 - Protein, total, except by refractometry; urine.

7. 85025 - Complete blood count (CBC) with automated differential white blood cell count.

8. 85027 - Complete blood count (CBC), automated (Hgb, Hct, RBC, WBC and platelet count).

9. 85048 - Blood count; leukocyte (WBC), automated.

10. 52000 - Cystourethroscopy (separate procedure).

11. 52005 - Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service.

12. 52204 - Cystourethroscopy, with biopsy(s).

These CPT codes are commonly used in conjunction with ICD code R31.9 to diagnose and manage conditions related to hematuria. However, the specific codes used will depend on the individual patient's clinical situation and the healthcare provider's judgment.

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