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

Vesicoureteral-reflux with reflux nephropathy without hydroureter, bilateral. This condition involves the backward flow of urine from the bladder into the ureters and kidneys, causing damage to the kidney tissue (nephropathy), but without dilation of the ureters (hydroureter). It affects both kidneys.

Example 1: A 5-year-old girl presents with recurrent urinary tract infections (UTIs). A VCUG reveals bilateral grade III vesicoureteral reflux and renal ultrasound shows evidence of nephropathy in both kidneys, but no hydroureter. The code N13.722 is used for this diagnosis., A 3-year-old boy is found to have bilateral VUR during a workup for urinary incontinence. Further imaging reveals early signs of reflux nephropathy without hydroureter. The diagnosis is coded as N13.722., A 6-year-old child with a history of febrile UTIs undergoes a VCUG demonstrating bilateral VUR. Renal ultrasound reveals bilateral reflux nephropathy, and there is no evidence of hydroureter. N13.722 accurately reflects this condition.

Documentation should include details of the diagnostic workup (VCUG, renal ultrasound findings), laterality (bilateral), presence of reflux nephropathy, and absence of hydroureter. The grade of VUR should also be documented.

** HCPCS code L8604 is used for Deflux, an injectable bulking agent often used to treat VUR. CPT code 52327 is used for the procedure of cystourethroscopy with subureteric injection of implant material.