2025 ICD-10-CM code R30.0
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified - Symptoms and signs involving the genitourinary system Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Dysuria, or painful urination, is a symptom often associated with urinary tract infections (UTIs), bladder infections, or other urological problems.
Medical necessity for the use of R30.0 is established by the presence of documented dysuria.The code reflects the patient's chief complaint and serves to communicate the presence of this symptom for billing and medical record purposes. If the underlying cause of the dysuria is identified and documented, then the code for that underlying condition must be used.
The clinical responsibility for coding R30.0 rests with the healthcare provider who documents the patient's symptoms.The provider should ensure that the documentation clearly supports the use of this code. Accurate coding requires a thorough evaluation and appropriate medical record keeping.If further investigations determine a specific diagnosis, that diagnosis code should be used instead of R30.0.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- Symptoms and signs involving the genitourinary system (R30-R39)
In simple words: This code means the patient has pain or discomfort when they pee.It's a symptom, not a disease itself, and could be from a bladder infection, kidney infection, or another problem.
R30.0 in the ICD-10-CM classification system denotes dysuria, characterized by pain or discomfort during urination.It's frequently a symptom of various conditions, including urinary tract infections (UTIs), bladder infections, urethritis, or other underlying urological issues.Dysuria can manifest in both men and women and might accompany other urinary symptoms like urinary frequency, urgency, or hematuria (blood in the urine).The code is used when dysuria is the primary presenting symptom and a more specific diagnosis hasn't yet been established.If a definitive diagnosis is determined (e.g., specific UTI), that diagnosis should be coded instead of R30.0.Strangury, a condition marked by painful and frequent urination with an urgent need to void, is also included under R30.0.
Example 1: A patient presents to the clinic complaining of burning and pain during urination.The provider performs a physical exam and orders a urinalysis, which reveals the presence of bacteria. The diagnosis of UTI is not yet confirmed. R30.0 is used. , An elderly patient reports difficulty and pain while urinating.No other specific urinary symptoms are noted. Following the exam, further diagnostics are ordered to determine the underlying cause.R30.0 is used as a preliminary code pending further investigations. , A patient with a history of interstitial cystitis reports worsening dysuria. The provider documents the increased pain and frequency but does not order more specific tests at this visit. R30.0 is used.
Detailed documentation of the patient's symptoms, including the nature of the pain (burning, sharp, aching), frequency of urination, and any other associated symptoms (urgency, frequency, hematuria).If a urinalysis or other diagnostic tests were performed, their results should be documented. Provider's assessment and plan for further investigation should also be documented to ensure proper code assignment.
** Dysuria can be a symptom of various conditions, and appropriate coding requires careful consideration of the clinical context and documentation.Always ensure the documentation supports the assigned code.
- Payment Status: Active
- Specialties:Urology, Family Medicine, Internal Medicine
- Place of Service:Office, Outpatient Hospital, Emergency Room - Hospital, Urgent Care Facility