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.

Figure 20-1 Gross anatomy of the urinary system (male).

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.

Figure 20-2 Normal male reproductive system.

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.

Figure 20-3 Normal female reproductive system.

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 (580-629) are located in Chapter 10 of the ICD-9-CM code book and are divided into the following categories:

CATEGORY	SECTION TITLES
580-589	Nephritis, Nephrotic Syndrome, and Nephrosis
590-599	Other Diseases of the Urinary System
600-608	Disease of the Male Genital Organs
610-611	Disorders of Breast
614-616	Inflammatory Disease of Female Pelvic Organs
617-629	Other Disorders of Female Genital Tract

It is important to note that disorders of the breast are classified as Diseases of the Genitourinary System in ICD-9-CM and ICD-10-CM.

Diseases of the Genitourinary System (N00 to N99), Chapter 11 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

Nephritis, Nephrotic Syndrome, and Nephrosis

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)

Goodpasture’s syndrome

Immunoglobulin (Ig)A nephropathy (Berger’s disease)

IgM mesangial proliferative glomerulonephritis

Lupus nephritis

Membranoproliferative glomerulonephritis I

Membranoproliferative glomerulonephritis II

Poststreptococcal glomerulonephritis

Rapidly progressive (crescentic) glomerulonephritis

Rapidly progressive glomerulonephritis (RPGN)

Example

Minimal change glomerulonephritis, 581.3 (N05.0).

Example

RPGN, 583.4 (N01.9).

Nephrotic Syndrome/Nephrosis

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.

Example

Lupus nephritis, 710.0, 583.81 (M32.14).

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.

Example

Patient is admitted with an exacerbation of congestive heart failure. The patient is also in acute renal failure. This physician documents that the ARF is due to the patient’s fluid overload, 428.0, 584.9 (I50.9, N17.9).

When a patient is admitted to the hospital with acute renal failure and dehydration, according to Coding Clinic (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.

Example

Acute renal failure due to dehydration, 584.9, 276.51 (N17.9, E86.0).

Chronic Renal Failure (CRF)/Chronic Kidney Disease (CKD)

According to Coding Clinic (2005:4Q:p77-79),² “Changes were made to the ICD-9-CM classification to recognize more current terminology related to chronic kidney disease (CKD) rather than imprecise terms like chronic renal failure [CRF] and chronic renal insufficiency (CRI). The descriptor for code 585, Chronic renal failure, has been changed to chronic kidney disease. Code 585 has been expanded to recognize current staging of chronic kidney disease developed by the National Kidney Foundation (NKF)” (Table 20-1).

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 slowly progress 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.

CRF or 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:

1. Markedly elevated values of serum creatinine or blood urea nitrogen (BUN), or diminished creatinine clearance

2. Other clinical and laboratory manifestations of renal impairment are as follows:

• Renal osteodystrophy

• Uremic symptoms: nausea, vomiting, itching, hemorrhagic conditions, hypertension, edema, dyspnea, lethargy, coma, etc.

Example

Hyperkalemia due to chronic kidney disease (CKD), 276.7, 585.9 (E87.5, N18.9).

Hypertension and Chronic Kidney Disease/Renal Failure

ICD-9-CM presumes a cause-and-effect relationship with hypertension and chronic renal failure or chronic kidney disease. This is addressed in the coding guidelines. Code 585 (N18.–) has instructions to code first hypertensive chronic kidney disease, if applicable. The physician would have to specifically document that CKD or renal failure 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.

Example

Patient has chronic kidney disease, stage 3, and benign hypertension, 403.10, 585.3 (I12.9, N18.3).

Example

Patient has chronic renal insufficiency and hypertension, 403.90, 585.9 (I12.9, N18.9).

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 renal failure/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.

Example

Patient is admitted for treatment of uncontrolled diabetes mellitus, type II. Patient is on hemodialysis for end-stage renal disease, 250.02, 585.6, V45.11 (E11.65, N18.6, Z99.2).

Example

Patient had intercapillary glomerulosclerosis due to diabetes mellitus type I, 250.41, 581.81 (E10.21).

Exercise 20-1

Assign codes to the following conditions.

1. Acute on chronic renal failure	_______________
2. Nephrotic syndrome	_______________
3. Nephritis due to tuberculosis	_______________
4. Focal segmental glomerulosclerosis	_______________
5. Essential hypertension; stage IV CKD	_______________