Vesicoureter-reflux w reflux nephrop w/o hydrourt, bi

This code describes a congenital or acquired condition where urine flows backward from the bladder into both ureters and kidneys, causing kidney damage (reflux nephropathy). Importantly, this specific code indicates that there is no dilation of the ureters associated with the bilateral reflux and kidney damage.

Use this code for patients diagnosed with bilateral vesicoureteral reflux (VUR) that has led to kidney scarring or dysfunction, confirmed by imaging studies such as voiding cystourethrogram (VCUG) and renal scans. Documentation must explicitly state the presence of reflux nephropathy and the absence of hydroureter on both sides.

• Ensure documentation specifies "bilateral" involvement and "without hydroureter."
• Do not confuse with codes for VUR without reflux nephropathy or VUR with hydroureter.
• Always sequence this code after any underlying cause of secondary VUR, if applicable.