2025 ICD-10-CM code N36.41
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Other diseases of the urinary system - Urethral functional and muscular disorders Diseases of the genitourinary system (N00-N99) Feed
Hypermobility of the urethra, a condition where the urethra is excessively mobile.
Medical necessity is established through the presence of symptoms (e.g., urinary incontinence) related to urethral hypermobility. The diagnostic testing and clinical findings should support the diagnosis.
Urologist or other qualified healthcare professional specializing in urinary tract disorders.
In simple words: Hypermobility of the urethra means the tube that carries urine from the bladder to the outside of the body is too loose and moves around too much. This can cause urine leakage, especially when you cough, sneeze, or laugh.
Hypermobility of the urethra (N36.41) refers to excessive mobility or laxity of the urethra. This condition can lead to urinary incontinence, particularly stress incontinence, due to insufficient support of the urethra.The diagnosis involves a thorough clinical evaluation, potentially including physical examination, imaging studies (such as ultrasound or cystourethroscopy), and urodynamic testing to assess urethral function and mobility.
Example 1: A female patient presents with urinary incontinence, especially during physical activity like coughing or lifting. Physical examination reveals hypermobility of the urethra, confirmed by urodynamic studies.Code N36.41 is assigned., A patient with a history of multiple vaginal deliveries experiences stress incontinence.Urological evaluation confirms urethral hypermobility. The physician documents the diagnosis and assigns code N36.41. Code N39.3 (Urinary stress incontinence) may also be assigned., During a routine physical exam, a female patient reports occasional urine leakage.A pelvic exam reveals urethral hypermobility. Code N36.41 is used to describe this finding, with additional codes potentially needed based on the patient's symptoms and other diagnoses.
Detailed history of urinary symptoms, physical examination findings documenting urethral hypermobility, results of any imaging studies (e.g., ultrasound, cystourethroscopy), and urodynamic testing results if performed.The physician's assessment and diagnosis supporting the code assignment are crucial.
** This code is primarily used in female patients, although it can potentially occur in males.Accurate documentation is key to appropriate coding and reimbursement.
- Payment Status: Active
- Specialties:Urology, Gynecology
- Place of Service:Office, Hospital (inpatient or outpatient), Ambulatory Surgical Center