Diseases of the Genitourinary System
(ICD-10-CM Chapter 14, Codes N00-N99)
Learning Objectives
2. Identify pertinent anatomy and physiology of diseases of the genitourinary system
3. Identify diseases of the genitourinary system
4. Assign the correct Z codes and procedure codes related to the genitourinary system
5. Identify common treatments, medications, laboratory values, and diagnostic tests
6. Explain the importance of documentation in relation to MS-DRGs for reimbursement
Abbreviations/Acronyms
CAPD continuous ambulatory peritoneal dialysis
CCPD continuous cycling peritoneal dialysis
CIN cervical intraepithelial neoplasia
CRI chronic renal insufficiency
DIEP deep inferior epigastric perforator
ESWL extracorporeal shock wave lithotripsy
FSG focal segmental glomerulosclerosis
GFR glomerular filtration rate
HSIL high-grade squamous intraepithelial lesion
ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification
ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification
ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System
LAVH laparoscopically assisted vaginal hysterectomy
LDMF latissimus dorsi musculocutaneous flap
LSIL low-grade squamous intraepithelial lesion
LUTS lower urinary tract symptoms
MRSA methicillin-resistant Staphylococcus aureus
MS-DRG Medicare Severity diagnosis-related group
NEC not elsewhere classifiable
NKF National Kidney Foundation
OIG Office of the Inspector General
PID pelvic inflammatory disease
RPGN rapidly progressive glomerulonephritis
SIEA superficial inferior epigastric artery
SIL squamous intraepithelial lesion
TRAM transverse rectus abdominis musculocutaneous
TULIP transurethral ultrasound-guided laser-induced prostatectomy
TUMT transurethral microwave thermotherapy
TUNA transurethral needle ablation of prostate
TURP transurethral resection of the prostate
UHDDS Uniform Hospital Discharge Data Set
VIN vulvular intraepithelial neoplasia
VLAP visual laser ablation of the prostate
ICD-10-CM Official Guidelines for Coding and Reporting
Please refer to the companion Evolve website for the most current guidelines.
14. Chapter 14: Diseases of Genitourinary System (N00-N99)
1) Stages of chronic kidney disease (CKD)
The ICD-10-CM classifies CKD based on severity. The severity of CKD is designated by stages 1-5. Stage 2, code N18.2, equates to mild CKD; stage 3, code N18.3, equates to moderate CKD; and stage 4, code N18.4, equates to severe CKD. Code N18.6, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD).
If both a stage of CKD and ESRD are documented, assign code N18.6 only.
2) Chronic kidney disease and kidney transplant status
Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0, Kidney transplant status. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.
3) Chronic kidney disease with other conditions
Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the Tabular List.
See I.C.9. Hypertensive chronic kidney disease.
See I.C.19. Chronic kidney disease and kidney transplant complications.
Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Coding Guidelines as found in Chapters 6 and 7.
Anatomy and Physiology
Urinary Tract
The kidneys, ureters, urinary bladder, and urethra form the urinary tract (Figure 20-1). Its main function involves producing, storing, and excreting urine. The kidneys and ureters make up the upper urinary tract, and the bladder and urethra constitute the lower urinary tract. The kidneys are two bean-shaped organs that are located on either side of the spine or retroperitoneally. The kidneys form a complex filtration system that cleanses the blood of waste products that become urine. Each kidney has a ureter that allows the urine to travel to the bladder for storage. The bladder is expandable, and openings into the ureters close so that urine cannot flow backward or reflux into the kidneys. The urine is excreted out of the body through a tube called the urethra. It is easy to confuse the terminology for urethra and ureter. Less than half of a single kidney is needed to do all the work that can be accomplished by two kidneys. The main difference between the male and female urinary tracts is the length of the urethra. The male urethra is 20 cm long; the female urethra measures only 3 cm.
Male Genital Tract
The main parts of the male genital or reproductive tract are the testes, epididymis, vas deferens, seminal vesicles, prostate, and penis (Figure 20-2). Its primary function is the production of sperm. The main diseases related to the male genital tract are infertility, infection, and tumor.
Female Genital Tract
The main parts of the female genital or reproductive tract are the vulva, vagina, uterus, fallopian tubes, and ovaries (Figure 20-3). Reproduction is its primary function. The main diseases and conditions of the female genital tract are related to infection, tumor, hormonal disorders, and pregnancy.
Breast
Male and female breasts are similar in that they are formed embryologically from the same tissues. It is possible for males to have breast disorders also. The female breast (Figure 20-4) will start to develop during puberty due to the hormone estrogen. Female breasts are considered an accessory organ of reproduction and are composed of fat and fibrous tissue with mammary glands for the production of milk (lactation).
Disease Conditions
Diseases of the Genitourinary System, Chapter 14 in the ICD-10-CM code book, are divided into the following categories:
| CATEGORY | SECTION TITLES |
| N00-N08 | Glomerular diseases |
| N10-N16 | Renal tubulo-interstitial diseases |
| N17-N19 | Acute renal failure and chronic kidney disease |
| N20-N23 | Urolithiasis |
| N25-N29 | Other disorders of the kidney and ureter |
| N30-N39 | Other diseases of the urinary system |
| N40-N51 | Diseases of male genital organs |
| N60-N65 | Disorders of the breast |
| N70-N77 | Inflammatory diseases of female pelvic organs |
| N80-N98 | Noninflammatory disorders of the female genital tract |
| N99 | Intraoperative and postprocedural complications and disorders of genitourinary system, not elsewhere classified |
It is important to note that disorders of the breast are classified as Diseases of the Genitourinary System in ICD-10-CM.
Genitourinary diseases that are due to communicable infections may be classified in Chapter 1, Certain Infectious and Parasitic Diseases. Also, any genitourinary conditions that occur during pregnancy, childbirth, and the puerperium will be coded in accordance with the Obstetrical guidelines.
Glomerular Diseases (N00-N08)
Nephritic Syndrome/Nephrotic Syndrome
Nephrotic syndrome is a condition that is marked by proteinuria (protein in the urine), low levels of protein in the blood, hypercholesterolemia, and swelling of the eyes, feet, and hands. Damage to the kidneys’ glomeruli can result in nephrotic syndrome. Treatment focuses on identifying the underlying cause and reducing cholesterol, blood pressure, and protein in urine through diet and medications.
Glomerulonephritis
Glomerulonephritis (GN) (Figure 20-5) is inflammation of the glomeruli of the kidneys. (See Figure 20-6 for illustration of the anatomy of the kidney.) Glomerulonephritis can be a temporary, reversible condition, or it may be a chronic progressive condition that results in chronic renal failure and end-stage renal disease. GN may cause hypertension and may not be discovered until the hypertension becomes difficult to control. Specific disorders that are associated with glomerulonephritis include the following:
Focal segmental glomerulosclerosis (FSG)
Immunoglobulin (Ig)A nephropathy (Berger’s disease)
IgM mesangial proliferative glomerulonephritis
Membranoproliferative glomerulonephritis I
Membranoproliferative glomerulonephritis II
Poststreptococcal glomerulonephritis
Rapidly progressive (crescentic) glomerulonephritis
Exercise 20-1
Assign codes to the following conditions.
| 1. Nephrotic syndrome | _______________ |
| 2. Nephritis due to lupus | _______________ |
| 3. Focal segmental glomerulonephritis | _______________ |
Renal Tubulo-Interstitial Diseases (N10-N16)
Renal tubulo-interstitial diseases involve the structures in the kidney outside the glomerulus. These conditions generally affect the tubules and/or the interstitium of the kidney and not the glomeruli. Some of the more common conditions in this section include acute pyelonephritis, hydronephrosis, and vesicoureteral reflux.
Pyelonephritis involves the kidneys and is an upper urinary tract infection. The most common cause is due to organisms from the intestinal tract (E. coli and Enterococcus faecalis) entering the urinary tract. It may initially start out as a lower urinary tract infection such as cystitis or prostatitis. Common symptoms include:
Chronic, recurrent infections can result in damage and scarring of the kidneys (Figure 20-7). In patients with recurrent infections, it may be necessary to do further testing to determine if there are some structural abnormalities such as vesicoureteral reflux, polycystic disease, or some other cause.
Vesicoureteral reflux (VUR) is an abnormality in the flow of urine from the bladder into the ureters and/or kidneys. The normal flow is from the kidneys through the ureter into the bladder. In VUR the urine flows backwards. Damage to the kidney(s) may occur depending of the severity of the reflux and other complications such as recurrent urinary tract infections.
Hydronephrosis is abnormal dilatation of the renal pelvis that is caused by pressure from urine that cannot flow past an obstruction in the urinary tract (Figure 20-8). Hydroureter is the accumulation of urine in the ureters. These conditions may be documented in x-ray reports, ultrasound, or other diagnostic tests, but they must be documented by a physician before code assignment. Obstruction can result from a stone, tumor, infection, prostatic hypertrophy, or congenital abnormalities.
Exercise 20-2
Assign codes to the following conditions.
| 1. Acute and chronic pyelonephritis due to Pseudomonas | _______________ |
| 2. Hydronephrosis due to kinking of ureter | _______________ |
| 3. Bilateral VUR with hydroureter | _______________ |
| 4. Obstructive uropathy | _______________ |
Acute Renal Failure and Chronic Kidney Disease (N17-N19) and Urolithiasis (N20-N23)
Acute Renal Failure
Acute renal failure (ARF) is sudden and severe impairment in renal function characterized by oliguria, increased serum urea, and acidosis. With treatment, ARF is usually reversible. ARF often occurs in hospitalized patients with serious systemic illness such as infection, low blood pressure, shock, and as an adverse effect of the use of certain antibiotics and drugs. Obstruction of the urinary tract and dehydration may also cause ARF. It is possible for a patient with chronic renal failure or chronic kidney disease to also develop ARF. In this case, codes are assigned for both the acute and chronic renal failure.
If a patient is admitted for multiple reasons including ARF, the guidelines for principal diagnosis selection need to be applied. Often times, the acute renal failure is a result of another condition and should be coded as a secondary diagnosis.
When a patient is admitted to the hospital with acute renal failure and dehydration, according to Coding Clinic for ICD-9-CM (2002:3Q:p21-22),1 ARF is the principal diagnosis, and the dehydration is a secondary diagnosis. Patients with both conditions are generally treated with IV fluids, and ARF is more serious than dehydration. A patient who is dehydrated and has no impairment in renal function may be given IV fluids and sent home instead of being admitted to the hospital.
Chronic Kidney Disease (CKD)
Codes for chronic kidney disease (CKD) identify the various stages of CKD that were developed by the National Kidney Foundation (NKF) (Table 20-1). In the past, CKD has been documented with imprecise terms such as chronic kidney failure (CRF) and chronic renal insufficiency (CRI).
TABLE 20-1
FIVE STAGES OF CHRONIC KIDNEY DISEASE
| Stage | Description | Glomerular Filtration Rate (GFR) |
| At increased risk | Risk factors for kidney disease (e.g., diabetes, high blood pressure, family history, older age, ethnic group) | Higher than 90 |
| 1 | Kidney damage (protein in the urine) and normal GFR | Higher than 90 |
| 2 | Kidney damage and mild decrease in GFR | 60-89 |
| 3 | Moderate decrease in GFR | 30-59 |
| 4 | Severe decrease in GFR | 15-29 |
| 5 | Kidney failure (dialysis or kidney transplant needed) | Less than 15 |
Data from the National Kidney Foundation.
Using these NKF guidelines, levels of kidney damage and kidney function must be determined to accurately assign the code for CKD. A patient’s glomerular filtration rate (GFR) indicates the level of kidney function and indicates the stage of the disease, which may progress slowly over many years. Early detection through laboratory tests and proper treatment can limit the effects of CKD, if the disease is discovered in the early stages.
If CKD is left untreated, a patient will develop end-stage renal disease (ESRD). This condition is characterized by the near or complete failure of kidney function, which leaves the patient unable to process waste material. Dialysis or transplantation may be needed to treat the condition.
CKD can develop from ARF if renal function is not restored through dialysis or treatment. This may take several weeks or months. Documentation in the health record that might indicate the presence of renal failure could include the following:
Hypertension and Chronic Kidney Disease
ICD-10-CM presumes a cause-and-effect relationship with hypertension and chronic kidney disease. This is addressed in the coding guidelines. Code N18.– has instructions to code first hypertensive chronic kidney disease, if applicable. The physician would have to specifically document that CKD is NOT due to hypertension to negate the cause-and-effect relationship. Hypertension and hypertensive manifestations are discussed more extensively in Chapter 15, Diseases of the Circulatory System.
Diabetic Nephropathy
Diabetes mellitus can have effects on many organs, including the kidneys. If diabetes is not well controlled, it may cause renal complications such as glomerulosclerosis, pyelonephritis, and papillary necrosis. Diabetic patients with renal manifestations may be prone to infections that can cause further damage to the kidneys.
Unlike the relationship between chronic kidney disease and hypertension, diabetes and renal disease must be linked in a manner that denotes a direct relationship. For example, diabetic nephropathy or intercapillary glomerulosclerosis due to diabetes shows a cause-and-effect relationship with diabetes. It is possible for a patient to have nephropathy and diabetes, and no documentation indicates that nephropathy is due to diabetes. In Chapter 12 of this book, diabetes mellitus and manifestations of the disease are discussed in greater depth.
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