ICD Code R33.9

ICD code R33.9 is used to indicate a diagnosis of retention of urine, unspecified. This code is applied when a patient experiences difficulty in urinating or is unable to completely empty the bladder, but the specific cause of the urinary retention is not identified or documented. It is a general code used when more detailed information about the condition is not available.

1. Inability to Urinate: The patient experiences a complete inability to pass urine, which may be acute or chronic in nature.

2. Bladder Distention: Physical examination reveals a distended bladder, often accompanied by discomfort or pain in the lower abdomen.

3. Frequent Urination Attempts: The patient reports frequent attempts to urinate with little to no success, often resulting in only a small amount of urine being passed.

4. Weak Urine Stream: When urination does occur, the stream is weak or intermittent, indicating potential obstruction or dysfunction.

5. Post-Void Residual Urine: Diagnostic imaging or ultrasound shows a significant amount of urine remaining in the bladder after an attempt to void.

6. Urinary Hesitancy: The patient experiences difficulty initiating urination, often with a delay between the urge to urinate and the actual flow of urine.

7. Recurrent Urinary Tract Infections (UTIs): The patient has a history of recurrent UTIs, which may be associated with incomplete bladder emptying.

8. Pelvic Pain or Discomfort: The patient reports persistent pelvic pain or discomfort, which may be exacerbated by attempts to urinate.

9. Neurological Symptoms: The presence of neurological symptoms such as numbness or weakness in the lower extremities, which may suggest a neurogenic cause of urinary retention.

10. Recent Surgical History: The patient has undergone recent pelvic or abdominal surgery, which may contribute to postoperative urinary retention.

11. Medication Review: The patient is taking medications known to cause urinary retention, such as anticholinergics or certain antidepressants.

12. Prostate Enlargement: In male patients, an enlarged prostate is noted, which may obstruct the flow of urine and lead to retention.

13. History of Bladder Dysfunction: The patient has a documented history of bladder dysfunction or previous episodes of urinary retention.

For the ICD code R33.9 (Retention of urine, unspecified), the relevant CPT codes that may be applicable for treatment include:

1. 51701 - Insertion of non-indwelling bladder catheter (e.g., straight catheterization for residual urine)

2. 51702 - Insertion of temporary indwelling bladder catheter; simple (e.g., Foley)

3. 51703 - Insertion of temporary indwelling bladder catheter; complicated (e.g., altered anatomy, fractured catheter/balloon)

4. 51720 - Bladder instillation of anticarcinogenic agent (e.g., Bacillus Calmette-Guerin for bladder cancer)

5. 51725 - Simple cystometrogram (CMG) (e.g., spinal manometer)

6. 51726 - Complex cystometrogram (e.g., calibrated electronic equipment)

7. 51741 - Complex uroflowmetry (e.g., calibrated electronic equipment)

8. 51784 - Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique

9. 51798 - Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging

These CPT codes are examples of procedures that may be performed to diagnose or treat urinary retention associated with ICD code R33.9. It is important for healthcare providers to select the most appropriate CPT code based on the specific clinical scenario and services provided.

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