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2025 ICD-10-CM code R39

This code encompasses other and unspecified symptoms and signs related to the genitourinary system not classified elsewhere.

Use this code only when a more specific code is not available. Review the ICD-10-CM guidelines to confirm accurate code assignment.

Medical necessity must be established by documenting the clinical rationale for using this code.This involves linking the symptoms and signs to the underlying condition or medical issue affecting the genitourinary system.

In simple words: This code represents various unexplained or unspecified urinary symptoms and signs.

This code is used for symptoms and signs involving the genitourinary system that are not classified elsewhere. It includes conditions where a more specific diagnosis cannot be made even after investigation, transient symptoms with undetermined causes, provisional diagnoses for patients who did not return for further care, cases referred elsewhere before diagnosis, and situations where a more precise diagnosis was unavailable for any other reason.

Example 1: A patient presents with urinary hesitancy and a poor stream, but further investigation does not reveal a specific cause. R39.1 would be appropriate., A patient experiences transient urinary retention after surgery, but the cause is undetermined and the retention resolves. R39 would be used., A patient reports unspecified genitourinary discomfort, and further investigation is pending or the patient is referred elsewhere before a definitive diagnosis is made. R39 would be applicable.

Detailed documentation of the presenting symptoms, signs, and relevant clinical findings related to the genitourinary system is crucial. Any diagnostic tests performed and their results should also be recorded. If a more definitive diagnosis is made later, that diagnosis should be coded instead.

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