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2025 ICD-10-CM code N39.44

Nocturnal enuresis, also known as bedwetting, is the involuntary discharge of urine during sleep.

Code assignment should align with the patient's age, clinical presentation, and response to interventions. Always code to the highest degree of specificity.

Modifiers may be applied in conjunction with other codes reported along with N39.44, as needed to convey specific circumstances (e.g., place of service, type of procedure, etc.).

Medical necessity for the diagnosis of nocturnal enuresis is established when a patient, typically a child or adolescent, experiences the involuntary passage of urine during sleep. The presence of nocturnal enuresis can lead to various psychosocial issues, which can impact the patient’s self-esteem and relationships. The medical necessity for treatment is supported by the use of appropriate modalities aimed at managing the symptoms and improving the patient's quality of life. Documentation should demonstrate the impact on the patient's functioning to justify the medical necessity of treatment.

The clinical responsibility involves diagnosing the underlying cause of nocturnal enuresis through history taking, physical examination, and possibly additional investigations such as urinalysis.Treatment strategies could include behavioral interventions (bladder training, fluid management), use of bed-wetting alarms, or pharmacological management depending on the individual's age, history, and response to initial treatments.

IMPORTANT Excludes1: enuresis NOS (R32); functional urinary incontinence (R39.81); urinary incontinence associated with cognitive impairment (R39.81); urinary incontinence NOS (R32); urinary incontinence of nonorganic origin (F98.0).Code also: any associated overactive bladder (N32.81). Excludes2: nocturnal polyuria (R35.81); hematuria NOS (R31.-); recurrent or persistent hematuria (N02.-); recurrent or persistent hematuria with specified morphological lesion (N02.-); proteinuria NOS (R80.-).

In simple words: Bedwetting, or nocturnal enuresis, is when someone pees in their bed while sleeping, usually after they're old enough to have learned to control their bladder. It happens because the bladder might be too small, they make more pee at night than it can hold, they sleep too soundly to wake up, or because they just take longer to learn bladder control.It's important to remember that it's not the person's fault and they don't do it on purpose.There are things that can help like special alarms, exercises, or medicines.

Nocturnal enuresis, commonly referred to as bedwetting, is defined as the involuntary passage of urine during sleep in individuals who are beyond the age at which urinary control is typically established. This condition affects children and adults, often stemming from various factors such as small bladder capacity, excessive nighttime urine production, deep sleep patterns hindering awareness of bladder fullness, or delayed bladder control development.It is crucial to note that nocturnal enuresis is not a behavioral issue and should not be subject to punitive measures.Effective management strategies often involve bed-wetting alarms, bladder training exercises, and in some cases, medication.

Example 1: A 7-year-old child presents with a history of nocturnal enuresis, with no other urinary symptoms.Physical exam and urinalysis are unremarkable. Treatment begins with bladder training, fluid restriction in the evening, and a bed-wetting alarm., An 8-year-old child with nocturnal enuresis and a family history of bedwetting undergoes urodynamic testing. The results show a small bladder capacity.The child is prescribed desmopressin to reduce nighttime urine production., A 15-year-old adolescent with a history of nocturnal enuresis is referred for further evaluation due to persistent bedwetting and new onset daytime urinary frequency.Psychological consultation is suggested, and the adolescent is assessed for possible emotional or psychological factors that may be contributing.

Detailed history of the onset and duration of nocturnal enuresis; frequency and severity of bedwetting episodes; family history of enuresis;assessment of bladder capacity (possibly via urodynamic studies);urinalysis to rule out urinary tract infection;physical examination noting any other findings; response to treatment;details about management strategies implemented (e.g., bladder training, medication, alarm usage).

** Consider additional codes for associated conditions such as overactive bladder (OAB) or other urinary tract issues if present.

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