2025 ICD-10-CM code N13.71
Vesicoureteral reflux without reflux nephropathy.
Medical necessity for services related to N13.71 is established by the presence of vesicoureteral reflux, which poses a risk of complications like recurrent urinary tract infections and potential kidney damage.Treatment aims to prevent these complications and preserve kidney function.
Diagnosis and management of vesicoureteral reflux typically falls under the purview of nephrologists (kidney specialists) or urologists. They are responsible for assessing the severity of the reflux, determining the underlying cause, and recommending appropriate treatment strategies. This may involve conservative management with regular monitoring, medical interventions to prevent urinary tract infections, or surgical correction in severe cases.
In simple words: This code refers to a condition where urine flows backward from the bladder into the tubes that connect the kidneys to the bladder (ureters), but it hasn't yet caused any damage to the kidneys.
Vesicoureteral reflux without reflux nephropathy. This condition involves the retrograde flow of urine from the bladder back into the ureters, but without associated kidney damage (nephropathy).
Example 1: A 4-year-old child presents with recurrent urinary tract infections. Diagnostic imaging reveals vesicoureteral reflux, but there are no signs of kidney damage. The appropriate code is N13.71., During a routine prenatal ultrasound, a fetus is found to have hydronephrosis. After birth, further evaluation confirms the presence of vesicoureteral reflux without any evidence of nephropathy.N13.71 is the correct code to describe this condition., An adult patient undergoes a cystourethrogram for evaluation of urinary incontinence. The imaging study shows mild vesicoureteral reflux, but the kidneys appear normal. The physician assigns code N13.71.
Documentation for N13.71 should include details of the diagnostic tests confirming vesicoureteral reflux (e.g., voiding cystourethrogram, radionuclide cystogram) and the absence of reflux nephropathy.Supporting clinical findings, such as the frequency and nature of urinary tract infections, should also be documented.
- Specialties:Nephrology, Urology, Pediatrics
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital