2025 ICD-10-CM code N36.4
Urethral functional and muscular disorders. Use additional code to identify associated urinary stress incontinence (N39.3).
Medical necessity must be established by documenting the symptoms and their impact on the patient's quality of life, along with the clinical findings supporting the diagnosis.
Diagnosis and management of conditions causing urethral functional and muscular disorders falls under the purview of urologists, gynecologists (for female patients), and sometimes primary care physicians.
- Diseases of the genitourinary system (N00-N99)
- N36 Other disorders of urethraN36.4 Urethral functional and muscular disordersN36.41 Hypermobility of urethraN36.42 Intrinsic sphincter deficiency (ISD)N36.43 Combined hypermobility of urethra and intrinsic sphincter deficiency N36.44 Muscular disorders of urethra
In simple words: This code refers to problems with how the urethra (the tube that carries urine out of the body) works due to muscle or functional issues.
Urethral functional and muscular disorders. This code is used to report issues related to the function and musculature of the urethra.An additional code should be used to identify any associated urinary stress incontinence (N39.3).
Example 1: A 55-year-old female presents with involuntary leakage of urine during coughing, sneezing, or lifting heavy objects. After examination and urodynamic studies, she is diagnosed with urethral hypermobility contributing to stress urinary incontinence. Both N36.41 and N39.3 are coded., A 60-year-old male reports difficulty initiating and maintaining a urine stream, along with a feeling of incomplete bladder emptying.Diagnostic testing reveals intrinsic sphincter deficiency (ISD). N36.42 is coded., A 40-year-old female experiences mixed urinary incontinence, with symptoms of both stress incontinence and urgency. Evaluation shows a combination of urethral hypermobility and intrinsic sphincter deficiency.N36.43 is coded, along with a code for the other type of incontinence.
Documentation should include details of the patient's symptoms, physical examination findings, urodynamic study results (if performed), and the physician's diagnosis specifying the type of urethral functional and muscular disorder.
- Payment Status: Active
- Specialties:Urology, Gynecology, Primary Care
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital