2025 ICD-10-CM code R33.9
Retention of urine, unspecified.
Medical necessity for the management of urinary retention depends on the underlying cause and the severity of the condition. Urinary retention can be a serious medical issue that requires prompt intervention to prevent complications, such as urinary tract infections or bladder damage.
The physician's responsibility is to determine the underlying cause of the urinary retention and to manage it appropriately. This may involve further investigation, such as a physical examination, urinalysis, blood tests, or imaging studies. Treatment may include catheterization to relieve the retention, medications to address the underlying cause, or surgical intervention if necessary.
In simple words: Inability to completely empty the bladder.
Retention of urine, unspecified.
Example 1: A 65-year-old male with benign prostatic hyperplasia presents with inability to urinate despite feeling a full bladder. He is diagnosed with urinary retention and a catheter is placed to drain the bladder. Code R33.9 is used to document the urinary retention., A 28-year-old female presents to the emergency room after a fall. She reports inability to urinate.A neurological exam suggests possible spinal cord injury.Imaging and consultation are obtained. Code R33.9 is used to document the urinary retention., A 40-year-old female presents with urinary retention following a surgical procedure. She is given medication to help with bladder emptying. Code R33.9 is used to document the urinary retention.
Documentation should include details of the patient's symptoms, the duration of the retention, any associated symptoms, and the results of any investigations or interventions performed. The physician’s clinical assessment and diagnostic workup should be clearly documented.
- Payment Status: Active