Diseases of the Genitourinary System
(ICD-9-CM Chapter 10, Codes 580-629, and ICD-10-CM Chapter 14, Codes N00-N99)
1. Apply and assign the correct ICD-9-CM and ICD-10-CM codes in accordance with Official Guidelines for Coding and Reporting
2. Identify major differences between ICD-9-CM and ICD-10-CM related to the genitourinary system
3. Identify pertinent anatomy and physiology of diseases of the genitourinary system
4. Identify diseases of the genitourinary system
5. Assign the correct V/Z codes and procedure codes related to the genitourinary system
6. Identify common treatments, medications, laboratory values, and diagnostic tests
7. Explain the importance of documentation in relation to MS-DRGs for reimbursement
ICD-9-CM Official Guidelines for Coding and Reporting
Please refer to the companion Evolve website for the most current guidelines.
10. Chapter 10: Diseases of Genitourinary System (580-629)
1) Stages of chronic kidney disease (CKD)
The ICD-9-CM classifies CKD based on severity. The severity of CKD is designated by stages I-V. Stage II, code 585.2, equates to mild CKD; stage III, code 585.3, equates to moderate CKD; and stage IV, code 585.4, equates to severe CKD. Code 585.6, 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 585.6 only.
2) Chronic kidney disease and kidney transplant status
Patients who have undergone kidney transplant may still have some form of 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 585 code for the patient’s stage of CKD and code V42.0. If a transplant complication such as failure or rejection is documented, see section I.C.17.f.2.b 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.3.a.4 for sequencing instructions for diabetes.
See I.C.4.a.1 for anemia in CKD.
See I.C.7.a.3 for hypertensive chronic kidney disease.
See I.C.17.f.1.b, Kidney transplant complications, for instructions on coding of documented rejection or failure.
Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Guidelines as found in Chapter 6.
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 Guidelines as found in Chapter 7.
Major Differences Between ICD-9-CM and ICD-10-CM
In ICD-10-CM the various stages of dysplasia of the vagina are identified.
In ICD-10-CM laterality is used to identify conditions under the N60 category, benign mammary dysplasia.
Procedural complications affecting the genitourinary system are included in Chapter 14 of ICD-10-CM. Some of the complications include:
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 (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 |
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)
Immunoglobulin (Ig)A nephropathy (Berger’s disease)
IgM mesangial proliferative glomerulonephritis
Membranoproliferative glomerulonephritis I
Membranoproliferative glomerulonephritis II
Poststreptococcal glomerulonephritis
Rapidly progressive (crescentic) glomerulonephritis
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.
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 (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 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:
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.
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.
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 | _______________ |
Other Diseases of the Urinary System
Hematuria
Hematuria is the presence of blood in the urine. Hematuria may be grossly visible, or it may be detected only through microscopic analysis. The causes of hematuria are varied, and some are more serious than others. The extent of diagnostic investigation required to determine a cause depends on the amount of hematuria, its duration, and risk factors the patient may have that indicate a more serious disease. Causes include inflammation due to drugs or medications, stones, infections, cancers or malignancies, trauma, and blockages or obstructions of flow. A patient with renal stones often has hematuria. Hematuria would not be assigned as an additional code because it is considered integral to the renal stones according to Coding Clinic (1995:3Q:p8).3 This corresponds with the general coding guideline that signs and symptoms that are integral to the disease process should not be assigned as additional codes.
Urinary Tract Infections
“Urinary tract infection” (UTI) is a general term that is used to describe infection of any area of the urinary tract. Cystitis is a lower tract infection that affects the bladder (Figure 20-7), and urethritis affects the urethra. An upper tract infection that involves the kidneys is called pyelonephritis (Figure 20-8).
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