Congenital ureterocele, orthotopic

This code describes a congenital anomaly where the distal end of the ureter, which is located in its normal anatomical position within the bladder (orthotopic), balloons out into the bladder lumen, forming a cyst-like structure. This malformation can obstruct urine flow and lead to hydronephrosis or recurrent urinary tract infections.

Use this code for patients diagnosed with a ureterocele that is present at birth and originates from a ureter entering the bladder at its typical location. Documentation should clearly specify "congenital" and "orthotopic" or describe the ureterocele's normal insertion point. This code is appropriate when the ureterocele is the primary diagnosis or a significant co-morbidity.

• Differentiate from ectopic ureterocele (Q62.32), where the ureter enters the bladder or urethra at an abnormal location.
• Ensure documentation specifies "congenital" as acquired ureteroceles are rare and coded differently.
• Code any associated complications, such as hydronephrosis (N13.x) or recurrent UTIs (N39.0), as secondary diagnoses.