2025 ICD-10-CM code R33
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings - Retention of urine Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Retention of urine; inability to empty the bladder completely.
Modifiers may be used to indicate the circumstances of the retention (e.g., location of service, type of procedure performed), but this will depend on the individual circumstances and applicable guidelines.
Medical necessity is established by the presence of symptoms of urinary retention and potential complications such as bladder distension, infection, or renal failure.Treatment should be based on the underlying cause.
Urologist, nephrologist, or other relevant specialists depending on the underlying cause.May involve nurses for monitoring and catheterization.
- 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 you can't empty your bladder completely.This could be due to a blockage, nerve or muscle problems, or medicine side effects.It can be painful and sometimes leads to accidental urination.
R33, Retention of urine, encompasses the inability to voluntarily urinate, leading to urine accumulation in the bladder.This condition can stem from various factors, including urethral obstruction (e.g., blockage, narrowing), dysfunction of bladder muscles or nerves, or medication side effects.The inability to urinate can cause pain and potentially lead to urinary incontinence.
Example 1: A 70-year-old male with benign prostatic hyperplasia (BPH) presents with urinary retention.He is unable to urinate and experiences suprapubic discomfort.A catheter is inserted to relieve retention., A 35-year-old female post-surgery experiences urinary retention due to opioid-induced bladder dysfunction. She reports a feeling of fullness and inability to void.Careful monitoring and supportive care are implemented., A 62-year-old man with a history of bladder cancer undergoes a transurethral resection of a bladder tumor, developing post-operative urinary retention, requiring bladder catheterization and careful monitoring.
History and physical examination documenting symptoms of urinary retention, including the duration, severity, and associated symptoms (e.g., pain, discomfort).Urinalysis, post-void residual (PVR) measurement, imaging studies (ultrasound, CT), and potentially uroflowmetry.
** Always consider the underlying cause of urinary retention for accurate coding and treatment.The use of a catheter and other supportive measures should be reflected in additional codes, if necessary.Consider R39.14 if the patient reports feeling the bladder is not fully empty after voiding.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Urology, Nephrology, Geriatrics, Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Emergency Room - Hospital, Ambulatory Surgical Center, Skilled Nursing Facility