Vesicoureter-reflux w reflux nephrop w hydrourt, bilateral

This code signifies a congenital or acquired condition where urine flows backward from the bladder into both ureters and kidneys, leading to kidney damage (reflux nephropathy) and dilation of both ureters (hydroureter). This bilateral involvement indicates a more severe or widespread impact on the urinary system.

Use this code when documentation explicitly states bilateral vesicoureteral reflux (VUR) complicated by both reflux nephropathy and hydroureter. This typically applies to patients with chronic VUR who have developed kidney scarring and ureteral distension as a result. Imaging reports (e.g., voiding cystourethrogram, renal ultrasound) confirming bilateral VUR, hydroureter, and evidence of nephropathy are crucial for accurate coding.

• Ensure documentation specifies bilateral involvement of both hydroureter and reflux nephropathy.
• Do not use this code if only unilateral involvement is documented; select the appropriate unilateral code.
• Code any associated chronic kidney disease (CKD) separately, as reflux nephropathy often leads to CKD.