AHA Coding Clinic® for ICD-9 - 2013 Issue 1; Ask the Editor - ICD-9-CM Coding
Bladder Stretch Injury Secondary to Urinary Retention
The patient was admitted with altered mental status secondary to myxedema. The provider noted that the patient had decreased urine output. Bladder scans consistently showed greater than a liter of urine retained. The urology consultant diagnosed bladder stretch injury secondary to urinary retention and recommended placing an indwelling Foley catheter. How should bladder stretch injury due to urinary retention be coded? ...
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Article Overview
This premium article explains how a bladder stretch injury secondary to urinary retention is presented in a clinical documentation scenario and how it is translated into diagnosis coding. It is intended for coders, CDI staff, and other revenue cycle professionals reviewing urinary retention-related documentation and related bladder findings. The article focuses on the diagnosis terms, the supporting clinical context, and the code assignment guidance discussed in the case.
Why This Topic Matters
Accurate coding of bladder and urinary retention-related documentation affects claim integrity, coded data quality, and consistency in reporting genitourinary conditions.
What You Will Learn
- How a bladder stretch injury is described in the clinical scenario
- How urinary retention is reflected in the documentation
- What coding guidance is discussed for the case context
- How the article connects terminology in the record to diagnosis coding
Who Should Read This
- Medical coders
- Clinical documentation integrity specialists
- Revenue cycle teams
- Urology coding staff
Codes Discussed
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