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2025 ICD-10-CM code N13.70

Vesicoureteral reflux, unspecified.

Excludes1: reflux-associated pyelonephritis (N11.0). Excludes2: calculus of kidney and ureter without hydronephrosis (N20.-), congenital obstructive defects of renal pelvis and ureter (Q62.0-Q62.3), hydronephrosis with ureteropelvic junction obstruction (Q62.11), obstructive pyelonephritis (N11.1).

Medical necessity for the evaluation and management of vesicoureteral reflux is established by the presence of symptoms (such as recurrent UTIs), abnormal findings on imaging studies indicating reflux, or other related complications.

Diagnosis and management of vesicoureteral reflux, which may involve specialties like urology, nephrology, or pediatric urology.

In simple words: Backward flow of urine from the bladder into the ureters (tubes that carry urine from the kidneys to the bladder), the cause of which is not specified.

Vesicoureteral reflux, unspecified

Example 1: A 2-year-old child presents with recurrent urinary tract infections. Diagnostic imaging reveals vesicoureteral reflux, but the specific type or grade is not documented. The diagnosis code N13.70 is assigned., An adult patient undergoes a routine health check-up. Ultrasound incidentally detects mild dilation of the ureters, suggesting possible vesicoureteral reflux. Further evaluation is inconclusive. N13.70 is used for the present finding., A pregnant woman with a history of urinary tract infections undergoes a voiding cystourethrogram. The report indicates the presence of vesicoureteral reflux, but no further details are available. N13.70 is assigned.

Documentation should include details of diagnostic imaging studies (such as voiding cystourethrogram or renal ultrasound) demonstrating reflux, clinical findings suggestive of reflux (like recurrent UTIs), and any associated symptoms.If any associated conditions are present, they need to be documented as well, e.g., hydronephrosis, reflux nephropathy, or any underlying causes identified.

** For more specific types of vesicoureteral reflux, refer to codes N13.71-N13.73.

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