Congenital vesico-uretero-renal reflux

This code describes the backward flow of urine from the bladder into the ureters and potentially up to the kidneys, present from birth. This reflux is due to an anatomical defect in the ureterovesical junction, leading to increased pressure in the urinary tract and potential kidney damage or recurrent urinary tract infections.

Use this code for patients diagnosed with primary or congenital vesicoureteral reflux (VUR). Documentation should clearly indicate a congenital etiology, often identified during infancy or childhood following investigations for recurrent UTIs, hydronephrosis, or abnormal voiding.

• Differentiate from acquired or secondary VUR, which would be coded differently.
• Specify laterality if documented (e.g., Q62.71 for unilateral, Q62.72 for bilateral).
• Code any associated complications, such as hydronephrosis (N13.0-N13.39) or chronic kidney disease (N18.-), as secondary diagnoses.