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Incomplete emptying vs. Retention

David Posted Thu 08th of October, 2015 13:00:41 PM

With ICD-9 we were using 788.21 for incomplete emptying and 788.20 for retention. However in ICD-10 the definition is now listed as "feeling of incomplete emptying" under R39.14
Would we use R39.14 if the patient is diagnosed with incomplete emptying? Or is that only if the patient comes in with the symptom stating they feel like they are not emptying? Would we then use R33.8 or R33.9?
Thank you

SuperCoder Answered Fri 09th of October, 2015 05:47:19 AM

Well, R39.14 (feeling of incomplete bladder emptying) is direct mapping to 788.20. If patient feel like they are NOT EMPTING then it is better to use R33.9 if reason of retention is not clear, if reason is known then code accordingly. Hope this helps!

David Posted Tue 13th of October, 2015 10:42:08 AM

So I am correct to say that if the provider states the patient has "incomplete emptying" and we would have used 788.21 in ICD-9, we are now to use R33.9 in ICD-10?

Do you have clarification on when we would use R39.14 now? Would this only be used now if the patient states they feel that they are not emptying and we can find anything else to code. In many cases either the provider does a PVR and finds that the patient is truely in retention or is not completely emptying, then we would use R33.9??

This is a very confusing change in ICD-10 :)

SuperCoder Answered Wed 14th of October, 2015 05:05:04 AM

Well, if you go clinically, when patient says that he is having incomplete emptying- so it is feeling only. Without feeling he can not tell that he is having incomplete emptying. So, for incomplete emptying R39.14 is the correct code. Append the code according to the patient's complained. This change of ICD-10 is not confusing, I suggest not to relate it with ICD-9. Just go with the description of the ICD-10 code, then you will be very much clear with it. Hope it helps!

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