Hematuria, Unspecified (R31.9)

Name of the Condition

• Commonly known as hematuria.
• Medical term: Hematuria, unspecified.

Summary

Hematuria refers to the presence of blood in the urine. The unspecified tag indicates that the underlying cause of the condition has not been determined. It may be a sign of various underlying conditions, some of which require medical attention.

Causes

• Urinary tract infections (UTIs)
• Kidney stones or diseases
• Bladder or kidney tumors
• Enlarged prostate in men
• Certain medications (e.g., blood thinners)
• Strenuous exercise causing temporary hematuria

Risk Factors

• Family history of kidney disease
• Older age, increasing the risk of cancer
• Recent urinary tract infection
• Intense physical activity
• Smoking, which can increase cancer risks

Symptoms

• Visible red, pink, or cola-colored urine
• Sometimes blood is only visible under a microscope (microscopic hematuria)
• Possible associated symptoms: frequent urination, painful urination, or abdominal pain, depending on the cause

Diagnosis

• Urinalysis to detect blood in the urine
• Imaging tests like ultrasound or CT scan to visualize urinary tract structures
• Cystoscopy for bladder examination
• Blood tests to identify possible kidney problems

Treatment Options

• Addressing underlying infections with antibiotics
• Medications to shrink an enlarged prostate
• Shock wave therapy or surgery for kidney stones
• Lifestyle changes if related to exercise or diet
• Monitoring as some cases of hematuria resolve without treatment

Prognosis and Follow-Up

• Prognosis depends on the underlying cause.
• Regular follow-up appointments to monitor kidney function or to assess treatment efficacy.
• Most cases resolve with appropriate treatment, but ongoing monitoring may prevent recurrence.

Complications

• Persistent hematuria can indicate serious kidney or bladder problems.
• Potential for chronic kidney disease or bladder cancer if underlying causes are untreated.

Lifestyle & Prevention

• Adequate hydration to support kidney function.
• Quitting smoking to lower cancer risk.
• Avoiding excessive use of medications that may irritate the kidneys.
• Engaging in regular, non-excessive exercise.

When to Seek Professional Help

• Visible blood in the urine, persistent urinary symptoms, or significant pelvic or abdominal pain.
• Recurrent urinary tract infections or discomfort during urination.

Additional Resources

• American Urological Association: https://www.urologyhealth.org/
• National Kidney Foundation: https://www.kidney.org/
• Mayo Clinic on Hematuria: https://www.mayoclinic.org/diseases-conditions/hematuria/symptoms-causes/syc-20355650

Tips for Medical Coders

• Ensure documentation captures any associated conditions or symptoms to support the unspecified code.
• Verify with the healthcare provider if additional information is available to code to a more specific hematuria category.
• Avoid confusion with similar urinary conditions by checking the complete patient diagnosis and history.