Genitourinary system
Improving Physician Documentation Specificity
Benign prostatic hypertrophy (BPH) - Document all associated urinary tract symptoms (e.g., BPH with urinary frequency & obstruction)
Bladder dysfunction - Document any associated urinary incontinence (e.g., neuromuscular bladder dysfunction with urge incontinence)
Cardiorenal syndrome/Hypertensive heart disease
Chronic kidney disease (CKD)
Cystitis
Erectile dysfunction, male
Nephritic syndrome - Document severity (acute,rapidly progressive, or chronic) and manifestations (glomerular disease, glomerular nephritis)
Nephrotic syndrome - Document manifestations (e.g., glomerular lesions, glomerular nephritis type)
Pyelonephritis - Document severity (acute, chronic), laterality, and if present with calculus or hydronephrosis
Urosepsis - do not use this term. There is no code for urosepsis.
Vesiculoureteral reflux - Document if with nephropathy (and hydroureter), congenital, Pyelonephritis with causative organism, and if unilateral or bilateral
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
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