Vesicoureteral-reflux, unspecified

This code represents the backward flow of urine from the bladder into the ureters, where the specific grade or laterality of the reflux is not documented. It indicates the presence of vesicoureteral reflux (VUR) without further clinical detail regarding its severity or the affected side(s).

Use this code when documentation confirms the diagnosis of vesicoureteral reflux but lacks specificity regarding the grade (e.g., Grade I, II, III) or whether it is unilateral or bilateral. This code is appropriate when the provider has not yet determined or documented these specific characteristics.

• Avoid using this code if the grade or laterality of VUR is specified; instead, select a more specific code from the N13.7 series.
• Query the provider for more specific documentation regarding the grade and laterality of VUR to allow for more precise coding.
• This code should be used as a last resort when no further information about the VUR's characteristics is available.