Overactive bladder is not a disease.
Whether, it is a group of urinary symptoms that can cause an urgency to urinate, experience incontinence, or an urge to urinate more frequently. Having one or more of these symptoms can have a negative impact on the quality of your life.
ICD 9 Code for Overactive Bladder
596.51 is the billable medical ICD 9 code for overactive bladder that can be used to indicate a diagnosis on a reimbursement claim.
However, since the ICD 10 code set has effectively replaced the ICD 9 from October 1, 2015, 596.51 can only be used for medical claims for cases with a date of service before this date. For cases after the date, use the equivalent ICD 10 code for overactive bladder i.e. N32.81
The code can be extended to bladder muscle dysfunction (overactive) as well as hyperactivity of the bladder.
As many as 30 percent of men and 40 percent of women in the US live with overactive bladder symptoms. Many people living with these symptoms don’t ask for help. They may feel embarrassed. Many people either don’t know how to talk with their health care provider about their symptoms, or they think there aren’t treatments that can help.
The good news is that a brief evaluation can determine whether there’s a specific cause for your overactive bladder symptoms. For healthcare physicians and doctors, it is important to properly diagnose the symptoms, identify the underlying cause, provide proper treatment, and then document the process using the right ICD codes to help compile administrative data.
Overactive bladder encompasses a collection of symptoms which include:
- Incontinence: When you have an urge to urinate, there can be leakage of urine
- Frequent urination: There is a noticeable increase in the number of times you urinate compared to what you previously experienced.
- Urinary urgency: The urge to urinate suddenly with failure to postpone the need to go to the washroom.
- Nocturia: The condition when you need to get up and urinate at least two times each night.
There are several reasons which can lead to an overactive bladder. Some common causes are:
- Weak pelvic muscles: Some factors, such as childbirth and pregnancy, can cause the pelvic muscle to become weak. As a result, the bladder sags which can cause leakage.
- Infections: Infections such as Urinary tract infection (UTI) can cause irritation to the bladder nerves due to which the bladder can contract abnormally.
- Nerve damage: Some diseases affect your nervous system which in effect disrupts the signals that are sent to the brain. Signals are sent to the brain and bladder sometimes, to empty at the wrong time.
- Alcohol and caffeine: Both alcohol and caffeine have a knack to dull the nerves, which affects the signals sent back and forth from the brain, leading to bladder overflow.
If you have one or more of the symptoms mentioned above, your healthcare physician will do some additional tests to rule out any infection first before diagnosing overactive bladder. Your physicians may also want to make sure that you’re emptying your bladder completely when you urinate.
Your doctor will look for clues that might also indicate contributing factors. Your appointment will likely include a:
- Medical history
- Physical exam, which may include a rectal exam and a pelvic exam in women
- Urine sample to test for infection, traces of blood or other abnormalities
- Focused neurological exam that may identify sensory problems or abnormal reflexes
A healthcare physician may also order additional tests to assess how well your bladder is functioning. These include:
- Measuring the urine in the bladder: To confirm if you are able to empty your bladder completely when urinating, your doctor may recommend this test to measure the amount of urine left after you urinate.
- Urine flow rate: Your doctor may ask you to urinate in a device called a uroflowmeter that catches and measures the urine, translating the data into a graph. This allows the physician to measure the volume and speed of your voiding.
- Bladder pressure: Cystometry is a test that measures pressure in your bladder and in the surrounding region as your bladder fills. During this test, your doctor uses a thin tube (catheter) to fill your bladder slowly with warm fluid. Another catheter with a pressure-measuring sensor is placed in the rectum or, for women, in the vagina. The sensor tells how much pressure your bladder has to exert to empty completely.
What is the ICD 9?
The International Classification of Diseases, Ninth Revision, is the official system of identifying and assigning code to medical procedures and diagnoses in the US. Until recent years, the ICD-9 was used to classify and code mortality data from death certificates, which has now been effectively replaced by the ICD-10 code set.
The ICD-9-CM consists of:
· a tabular list containing a numerical list of the disease code numbers in tabular form;
· an alphabetical index to the disease entries; and
· a classification system for surgical, diagnostic, and therapeutic procedures (alphabetic index and tabular list).
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