Vesicoureter-reflux w reflux nephropathy w hydroureter, unsp

This code describes a condition where urine flows backward from the bladder into the ureters and kidneys, leading to kidney damage (reflux nephropathy) and dilation of the ureter (hydroureter). The specific cause or type of vesicoureteral reflux (VUR) is not documented.

Use this code when documentation confirms the presence of vesicoureteral reflux, associated reflux nephropathy, and hydroureter, but the laterality or specific grade of VUR is not specified. This code is appropriate when the physician explicitly states "unspecified" or provides insufficient detail to assign a more specific code.

• Always seek clarification from the provider if laterality (left, right, bilateral) or the grade of VUR is not documented, as more specific codes exist.
• Do not use this code if only VUR is present without documented reflux nephropathy and hydroureter; other N13 codes are available for VUR alone.
• Consider sequencing this code after any underlying cause of the VUR, if known and documented.