ED Coding and Reimbursement Alert

Question: A patient presented to the ED complaining of pain during urination. An exam found the patient to have an inflamed urinary tract with an acute kidney infection. The ED physician inserted a catheter to assist in voiding, and administered antibiotics. How should I code this procedure?

Nevada Subscriber

Answer: Urinary tract infections (UTIs) fall into two categories: lower-tract bladder infections (cystitis) and upper-tract kidney infections (pyelonephritis). The most common pitfall of coding for UTIs is the ED doctor's failure to document all the information pertinent to the level of E/M he or she chose for the visit. Some doctors may give the coder a vague primary diagnosis (e.g., UTI), when in fact the patient had one or more problems that made the visit a higher-level service. In your case, the patient probably also had a high fever along with the acute kidney infection.

You should have no difficulty receiving reimbursement for testing to determine the infection (81007, Urinalysis; bacteriuria screen, except by culture or dipstick). The test results will determine the exact diagnosis (590.80, Pyelonephritis, unspecified; or 590.1x, Acute pyelonephritis). Code 590.9 (Infection of kidney, unspecified) may not be appropriate because the test results will reveal the exact degree of infection and this will help you code to the highest level of specificity.

Because the patient comes in with urinary tension, the catheterization is necessary for relieving the patient's immediate symptoms. You can report 53670* (Catheterization, urethra; simple) and an ED E/M code (99281-99285, Emergency department visit for the evaluation and management of a patient ). Although this is a starred procedure, many coders say they get better results by adding modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the code (99283-25).

In cases like the one you describe, you should review your local medical review policy to verify whether you can bill the urinalysis, catheterization and E/M service separately.

An injection of antibiotics, however, is bundled into the ED E/M professional service. It can be captured on the facility side.