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2025 ICD-10-CM code N31.9

Neuromuscular dysfunction of the bladder, unspecified.

Ensure that the most specific code possible is used. If the type of neuromuscular bladder dysfunction is known, use the more specific N31.0, N31.1, N31.2, or N31.8 codes as appropriate.Always code any associated urinary incontinence using additional codes from N39.3-N39.4.

Medical necessity for further investigation into the cause of the unspecified neuromuscular bladder dysfunction is established by the presence of significant urinary symptoms affecting the patient's quality of life.Further testing is needed to guide appropriate management and improve patient outcomes.

Urologists and other specialists involved in the management of urinary disorders are primarily responsible for diagnosing and managing conditions coded as N31.9.This often involves a thorough history, physical examination, urinalysis, and possibly neurologic evaluation.

IMPORTANT:This code should not be used if the specific type of neuropathic bladder (uninhibited, reflex, or flaccid) is known.In such cases, codes N31.0, N31.1, and N31.2 should be used respectively.Consider additional codes to specify associated urinary incontinence (N39.3-N39.4).

In simple words: This code means there's a problem with the nerves and muscles that control the bladder, but doctors don't yet know exactly what the problem is. More tests are needed to find out.

This code classifies neuromuscular dysfunction of the bladder without further specification of the type of dysfunction.It encompasses various conditions affecting the bladder's neuromuscular control, resulting in impaired bladder function.The lack of specification necessitates further clinical investigation to determine the precise nature of the dysfunction.

Example 1: A 60-year-old male patient presents with urinary retention and frequency, with a history of diabetes.Neurological examination reveals diminished sensation in the lower extremities.After a comprehensive evaluation, N31.9 is assigned to indicate unspecified neuromuscular bladder dysfunction possibly related to diabetic neuropathy., A 75-year-old female patient reports urinary urgency and incontinence. A urodynamic study reveals detrusor overactivity and impaired bladder emptying.N31.9 is used in this case pending further clarification of the underlying cause of the neuromuscular dysfunction., A 45-year-old patient with a spinal cord injury at T12 presents with incomplete bladder emptying.Initial assessment indicates neuromuscular bladder dysfunction, and N31.9 is temporarily used while further investigations are performed to identify the specific type of neuropathic bladder dysfunction.

Detailed history of present illness focusing on urinary symptoms (frequency, urgency, incontinence, retention), relevant past medical history (including neurological conditions, diabetes, spinal cord injuries, etc.), physical examination findings, results of urodynamic studies (if performed), and any other relevant investigations (such as neurologic evaluations).

** This code is often used as a temporary code pending further diagnostic evaluation to determine the precise type of bladder dysfunction.

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