2025 ICD-10-CM code N13.30
Unspecified hydronephrosis.
Medical necessity for the evaluation and management of hydronephrosis is established by the presence of signs and symptoms such as flank pain or abnormal imaging findings suggestive of urinary tract obstruction. Further investigation is often medically necessary to determine the underlying cause and guide treatment decisions.
The physician is responsible for documenting the presence of hydronephrosis and performing the necessary diagnostic tests to determine the underlying cause and assess the severity. This may involve imaging studies, urine tests, and blood work. The physician also determines the appropriate treatment based on the underlying cause and severity of the hydronephrosis.
In simple words: This code refers to a swollen kidney because urine can't drain properly, but the specific reason why isn't known.
Hydronephrosis is the swelling of a kidney due to a build-up of urine. It happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction in the urinary tract.This code specifies a hydronephrosis where the cause is not documented.
Example 1: A patient presents with flank pain and ultrasound reveals dilation of the renal pelvis and calyces, but the cause is not immediately apparent. N13.30 is used until further investigation reveals a specific cause., A newborn infant is found to have hydronephrosis on prenatal ultrasound, but the etiology is unknown. N13.30 is used until a definitive diagnosis can be made., A patient with a history of recurrent urinary tract infections presents with flank pain. Imaging shows hydronephrosis, but it is unclear whether it is caused by an obstruction, a stone, or another factor. N13.30 is used until the cause is determined.
Documentation should include imaging findings (e.g., ultrasound, CT scan) showing dilation of the renal pelvis and calyces. The physician should also document any associated symptoms, such as flank pain, nausea, vomiting, fever, and dysuria.If a cause can be determined after additional testing, that cause should be coded as well.
** Hydronephrosis can be unilateral or bilateral. Further investigation to identify the underlying cause is essential for appropriate management.Use iFrameAI for additional information and insights into coding hydronephrosis.
- Payment Status: Active
- Specialties:Urology, Nephrology, Radiology
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Office, Independent Clinic