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2025 ICD-10-CM code N13.72

Vesicoureteral reflux with reflux nephropathy without hydroureter.

Coding should align with the WHO ICD-10-CM guidelines.Appropriate laterality (unilateral or bilateral) should be specified when applicable, using additional codes as needed.

Modifiers may be applicable depending on the circumstances of the encounter and the services performed. Consult current modifier guidelines for more detail.

The medical necessity for coding N13.72 is established by the presence of vesicoureteral reflux and associated reflux nephropathy, confirmed by imaging and clinical findings.Documentation must support the diagnosis and exclude other conditions.

Urologist or Nephrologist

IMPORTANT:Related codes include N13.7 (Vesicoureteral reflux), N13.721 (Vesicoureteral reflux with reflux nephropathy without hydroureter, unilateral), N13.729 (Vesicoureteral reflux with reflux nephropathy without hydroureter, unspecified), N13.73 (Vesicoureteral reflux with reflux nephropathy with hydroureter).Excludes1: reflux-associated pyelonephritis (N11.0)

In simple words: This code describes a condition where urine flows backward from the bladder to the kidneys, causing kidney damage, but without swelling of the tubes connecting the kidneys to the bladder.

This ICD-10-CM code classifies vesicoureteral reflux (VUR) with associated reflux nephropathy, but without hydroureter.Vesicoureteral reflux is a condition where urine flows backward from the bladder to the ureters and kidneys. Reflux nephropathy is kidney damage caused by this backflow of urine.Hydroureter, or dilation of the ureter, is absent in this specific code.

Example 1: A 5-year-old child presents with recurrent urinary tract infections (UTIs).A voiding cystourethrogram (VCUG) reveals bilateral vesicoureteral reflux. Renal ultrasound demonstrates mild scarring consistent with reflux nephropathy, but no hydroureter., A 20-year-old female with a history of VUR presents for a follow-up.She has had no UTIs in the past year.Renal ultrasound shows evidence of mild scarring consistent with past reflux nephropathy, but no hydronephrosis or hydroureter., A 10-year-old boy presents with microscopic hematuria.VCUG demonstrates unilateral VUR, and renal ultrasound demonstrates mild unilateral reflux nephropathy but no hydroureter.

* Detailed history and physical examination, including documentation of UTIs and other symptoms.* Results of imaging studies such as VCUG, renal ultrasound, and potentially DMSA scan to assess renal function and scarring.* Relevant laboratory results, such as urinalysis and urine culture.

** Further evaluation may be necessary to determine the severity of VUR and the extent of renal damage.Management of VUR may range from observation to surgical intervention.

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