2025 ICD-10-CM code R39.1
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified - Other symptoms and signs involving the urinary system XVIII Feed
Other difficulties with micturition, such as hesitancy, weak stream, or splitting of the urinary stream.
Modifiers may be applicable depending on the circumstances of the encounter and the services provided.
Medical necessity would be established by documentation supporting the clinical evaluation and diagnostic testing to rule out other causes of micturition difficulties.The necessity of further investigation or follow-up depends on the severity and persistence of symptoms.
Urologist, nephrologist, or primary care physician depending on the patient's overall health and the nature of the micturition difficulty.A thorough history, physical examination, and potentially diagnostic tests might be required to determine the underlying cause.
In simple words: This code describes problems with peeing that aren't caused by something else and can include trouble starting, a weak stream, or urine splitting into two streams.
This code captures various difficulties experienced during urination that are not otherwise specified or categorized elsewhere.It includes conditions like hesitancy in initiating urination, a weak or interrupted urinary stream, and a splitting of the urinary stream.This code should be used when a more specific diagnosis is not possible or when the difficulties are transient and their cause remains undetermined after investigation.It is crucial to document all relevant findings and investigations performed to support the use of this code.
Example 1: A 65-year-old male patient presents with hesitancy and a weak urinary stream.He reports that it takes longer to urinate and that the stream is not as strong as it used to be.No other specific urinary symptoms are present.After a physical exam and urinalysis, the physician determines no specific etiology and codes R39.1., A 70-year-old female patient complains of urinary stream splitting into two streams.She reports no pain or other urinary symptoms.After a thorough work-up, including imaging studies, no cause is found and R39.1 is assigned., A 30-year-old male patient has transient difficulty with urination after a recent viral infection. The symptoms resolve without specific treatment, but are documented appropriately. No further diagnostic testing reveals a specific diagnosis, and therefore R39.1 is the most suitable code.
Detailed patient history including onset, duration, character, and associated symptoms of the micturition difficulty.Results of any relevant physical examinations, including digital rectal examination (DRE) in males.Documentation of any diagnostic tests performed (urinalysis, imaging studies, urodynamic studies as needed) and their results.Note any underlying medical conditions or medications that may be contributing factors.
** This code is frequently used in situations where further investigation is unavailable, or where temporary symptoms do not warrant further investigation.
- Payment Status: Active
- Specialties:Urology, Nephrology, Family Medicine
- Place of Service:Office, Hospital, Outpatient Clinic