Tuberculosis of the kidney and ureter is a rare but serious form of extrapulmonary tuberculosis caused by Mycobacterium tuberculosis. It can lead to significant renal impairment and systemic complications if not diagnosed and treated promptly. The ICD-10 Code A18.11 facilitates accurate diagnosis, documentation, and billing, ensuring proper management and reporting of this infectious disease in clinical settings.
What is ICD-10 Code A18.11 for Tuberculosis of kidney and ureter?
ICD-10 Code A18.11 specifically represents Tuberculosis of the kidney and ureter, indicating a localized infection that may arise from hematogenous spread of Mycobacterium tuberculosis. This code should be used in clinical documentation and billing when a patient presents with renal symptoms linked to tuberculosis, ensuring appropriate treatment and follow-up.
ICD-10 Code A18.11 – Clinical Definition and Explanation of Tuberculosis of kidney and ureter
Tuberculosis of the kidney and ureter is primarily caused by the spread of Mycobacterium tuberculosis from a primary pulmonary infection or through hematogenous dissemination. This condition can progress to renal failure and requires immediate medical intervention to prevent severe complications.
Key Clinical Features:
- Hematuria (blood in urine)
- Flank pain or abdominal discomfort
- Fever and night sweats
- Weight loss and malaise
ICD-10 Code A18.11 for Tuberculosis of kidney and ureter – SOAP Notes & Clinical Use
In SOAP notes, ICD-10 Code A18.11 is utilized to document the presence of tuberculosis affecting the kidney and ureter, aiding in the assessment of symptoms, diagnostic findings, and treatment plans. This code is relevant in both acute and chronic care settings.
What Does ICD-10 Code A18.11 for Tuberculosis of kidney and ureter Mean in SOAP Notes?
ICD-10 Code A18.11 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of tuberculosis affecting the kidney and ureter. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.
Treatment Options for ICD-10 Code A18.11 – Tuberculosis of kidney and ureter
Tuberculosis of the kidney and ureter necessitates urgent medical attention, often requiring hospitalization for effective management.
Antibiotic Therapy:
- Isoniazid (INH) for 6-9 months
- Rifampin (RIF) for 6-9 months
- Pyrazinamide (PZA) for the first 2 months
- Ethambutol (EMB) for the first 2 months
Supportive Care:
- Hydration and nutritional support
- Pain management
- Monitoring renal function
- Psychosocial support
Infection Control:
- Isolation precautions if pulmonary TB is suspected
- Education on transmission prevention
- Regular screening for contacts during outbreaks
How to Document Symptoms of Tuberculosis of kidney and ureter (ICD-10 A18.11) in SOAP Notes
Subjective:
- Patient reports flank pain and hematuria
- Complaints of fever and night sweats
- History of weight loss over the past month
- Previous exposure to tuberculosis
Objective:
- Elevated temperature (e.g., 101°F)
- Positive urine culture for Mycobacterium tuberculosis
- Imaging showing renal lesions
- Laboratory findings indicating renal impairment
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SOAP Note Guidelines for Diagnosing Tuberculosis of kidney and ureter (ICD-10 Code A18.11)
Assessment:
- Diagnosis: Tuberculosis of kidney and ureter, moderate severity
- ICD-10 Code: A18.11
- Contributing factors: History of pulmonary tuberculosis
- Potential complications: Renal failure
Plan:
- Initiate anti-tuberculous therapy as per guidelines
- Educate patient on medication adherence
- Schedule follow-up in 1 month for renal function monitoring
- Consider referral to infectious disease specialist
Treatment & Plan Section for ICD-10 Code A18.11 – Tuberculosis of kidney and ureter
- First-line pharmacologic treatment includes a combination of INH, RIF, PZA, and EMB.
- Non-pharmacologic strategies include nutritional support and hydration.
- Monitoring renal function and response to treatment is essential.
- Follow-up appointments should be scheduled to assess treatment efficacy and manage any complications.
Using ICD-10 Code A18.11 for Tuberculosis of kidney and ureter in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and clinical findings in the Subjective (S) and Objective (O) sections.
- Use A18.11 in conjunction with relevant CPT codes for billing.
- Document treatment plans that align with clinical guidelines to support justified billing.
- Maintain clear records of patient history and treatment response for compliance.
Related ICD-10 Codes Often Used with Tuberculosis of kidney and ureter
- A15.0 – Pulmonary tuberculosis, bacteriologically and histologically confirmed
- A18.12 – Tuberculosis of bladder
ICD-10 Code A18.11 in Medical Billing and Insurance for Tuberculosis of kidney and ureter
ICD-10 Code A18.11 is crucial for billing in hospital, ER, or infectious disease care settings, ensuring accurate reimbursement for services rendered.
Billing Notes:
- Document all relevant patient history and clinical findings to support the use of A18.11.
- Ensure that the diagnosis is clearly linked to the treatment provided in the medical record.
- Use A18.11 in the appropriate clinical context to avoid claim denials.
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99223 | Initial hospital care, typically 70 minutes or more of total time spent on the date of the encounter. |
| 36415 | Collection of venous blood by venipuncture. |
| 71045 | Radiologic examination, chest, single view, frontal. |
Frequently Asked Questions
Common Questions About Using ICD-10 Code A18.11 for Tuberculosis of kidney and ureter
What are the common symptoms of Tuberculosis of the kidney and ureter?
Common symptoms include flank pain, hematuria, fever, night sweats, and weight loss. Patients may also experience general malaise and abdominal discomfort.
How is Tuberculosis of the kidney and ureter diagnosed?
Diagnosis typically involves imaging studies, urine cultures, and clinical evaluation of symptoms. A positive culture for Mycobacterium tuberculosis confirms the diagnosis.
What is the treatment for Tuberculosis of the kidney and ureter?
Treatment usually involves a combination of antibiotics such as isoniazid, rifampin, pyrazinamide, and ethambutol for a duration of 6-9 months, depending on the patient's response.
Is Tuberculosis of the kidney and ureter contagious?
While the renal form of tuberculosis itself is not contagious, it often arises from pulmonary tuberculosis, which can be transmitted through respiratory droplets. Infection control measures are essential.
