Vesicoureteral-reflux without reflux nephropathy

This code signifies the retrograde flow of urine from the bladder back into the ureters, without any associated kidney damage or scarring. It represents a functional abnormality of the vesicoureteral junction where the valve mechanism fails, allowing urine to ascend.

Apply this code when documentation confirms vesicoureteral reflux (VUR) but explicitly states the absence of nephropathy, renal scarring, or other kidney damage. This is typically diagnosed via voiding cystourethrogram (VCUG) and renal ultrasound showing no parenchymal changes.

• Ensure documentation explicitly negates reflux nephropathy; otherwise, a code indicating nephropathy should be considered.
• Do not use this code if there is any mention of renal scarring, atrophy, or other kidney damage attributable to the reflux.
• Sequence this code as a primary diagnosis when VUR without nephropathy is the reason for the encounter, or as a secondary diagnosis if managing another condition alongside the VUR.