What information should be included when writing a urology referral order for a patient with a general urological condition, including relevant medical history and ICD 10 code?

Writing a Urology Referral Order

Your urology referral should include the patient's chief urological complaint with quantified symptom severity using validated tools (IPSS/AUA Symptom Score), relevant medical history including medications affecting urinary function, pertinent physical exam findings, completed baseline investigations (urinalysis, uroflowmetry if available, post-void residual), and the specific ICD-10 code corresponding to the primary urological condition prompting referral. 1

Essential Components of the Referral

Patient Demographics and Chief Complaint

• Document the patient's primary urological problem in their own words 1
• Specify whether symptoms are predominantly storage (frequency, urgency, nocturia, urgency incontinence) or voiding (hesitancy, intermittency, weak stream, straining, incomplete emptying) 1
• Include quantified symptom severity using the International Prostate Symptom Score (IPSS) or AUA Symptom Score—this is critical for treatment decisions and should never be omitted 1

Medical History Documentation

• List previous urological conditions, procedures, or surgeries 1
• Document relevant comorbidities affecting urinary function: cardiovascular disease, neurological conditions (spinal cord injury, pelvic trauma), endocrine disorders (diabetes, hypogonadism), and obesity 1, 2
• Include current medications, particularly those known to affect urinary function (antihypertensives, antidepressants, tranquilizers, anticholinergics) 1, 2

Risk Factor Assessment

• For hematuria cases: document smoking history with pack-years (>30 pack-years = high risk for urothelial cancer), occupational exposures to chemicals/dyes, and family history of urological cancers 1
• For erectile dysfunction: cardiovascular risk factors (hypertension, hyperlipidemia, diabetes), relationship factors, and psychosocial stressors 3, 2

Completed Investigations to Include

• Urinalysis results (essential for most urological conditions) 4
• Uroflowmetry if available (peak flow <12 mL/sec suggests obstruction) 4
• Post-void residual measurement by ultrasound 4, 1
• For suspected stricture: results of retrograde urethrography (RUG) or voiding cystourethrography (VCUG) if performed 4
• For erectile dysfunction: morning serum total testosterone, fasting glucose/HbA1c, lipid profile 3, 2

Quality of Life Impact

• Document impact on quality of life using the Disease Specific Quality of Life Question—this is crucial for treatment decisions and commonly overlooked 1
• For nocturia: include number of nighttime voids and consider attaching a frequency-volume chart 1

Common ICD-10 Codes for Urology Referrals

Lower Urinary Tract Symptoms

• N40.1 - Benign prostatic hyperplasia with lower urinary tract symptoms
• R33.8 - Other retention of urine
• R39.15 - Urgency of urination
• R35.0 - Frequency of micturition

Hematuria

• R31.0 - Gross hematuria
• R31.1 - Benign essential microscopic hematuria
• R31.9 - Hematuria, unspecified

Urinary Incontinence

• N39.41 - Urge incontinence
• N39.46 - Mixed incontinence
• R32 - Unspecified urinary incontinence

Erectile Dysfunction

• N52.9 - Male erectile dysfunction, unspecified
• N52.01 - Erectile dysfunction due to arterial insufficiency
• N52.1 - Erectile dysfunction due to diseases classified elsewhere

Urethral Stricture

• N35.9 - Urethral stricture, unspecified
• N35.012 - Post-traumatic urethral stricture, male, anterior urethra

Urinary Tract Infection

• N39.0 - Urinary tract infection, site not specified
• N30.00 - Acute cystitis without hematuria

Critical Pitfalls to Avoid

• Never submit a referral without quantified symptom severity using validated tools (IPSS/AUA Score)—this leads to inadequate treatment decisions 1
• Do not omit quality of life assessment—this is essential for determining treatment urgency and approach 1
• Failing to document completed baseline investigations forces the urologist to repeat testing, delaying care 5, 6
• For suspected malignancy (hematuria, elevated PSA), ensure risk stratification is documented to facilitate appropriate triage 1
• In erectile dysfunction cases, always document whether morning erections are present—this helps differentiate psychogenic from organic causes 3, 2