ICD-10-CM Billable Code

Q64.31

Congenital bladder neck obstruction

Clinical Classification Guidelines

Inclusion Terms

  • Congenital obstruction of vesicourethral orifice

Medical Intelligence & Overview

Congenital bladder neck obstruction is a condition present at birth where the passage from the bladder to the urethra is blocked or narrowed. This obstruction can disrupt normal urination and may lead to other urinary complications if not diagnosed and managed appropriately. It specifically involves a congenital anomaly of the vesicourethral orifice, the opening where the bladder releases urine into the urethra.

Causes & Symptoms

Clinical Causes: Developmental abnormalities during fetal growth affecting the bladder neck area Genetic factors that influence the formation of urinary tract structures Increased pressure or malformation of surrounding tissues during fetal development Rarely, other congenital syndromes associated with urinary tract anomalies

Key Symptoms: Difficulty starting urination or weak urinary stream Intermittent or incomplete urination Urinary retention or hesitation Frequent urinary tract infections Discomfort or pain in the pelvic area Possible urinary incontinence or dribbling

Diagnostic & Treatment

Diagnosis Path: Diagnosis of congenital bladder neck obstruction involves a combination of clinical evaluation and imaging studies, including:

Treatment Protocols: Managing congenital bladder neck obstruction typically involves surgical intervention to remove or bypass the obstruction and restore normal urine flow. Treatment options include:

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is Q64.31 a billable ICD-10 code?
Yes, Q64.31 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report Q64.31?
Clinical documentation must specify the nature of Congenital bladder neck obstruction and any associated comorbidities for accurate reporting.

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