ED Coding and Reimbursement Alert

Question: Our physician wrote “UTI” on a patient’s chart. How can we find the right ICD-10 code based on that?

Codify Subscriber

Answer: The first ICD-10-CM code that pops up when you search for “infection/urinary (tract)” is N39.0 (Urinary tract infection, site not specified). But when you dig further into the listing, you’ll find codes for UTIs that are associated with conditions such as pregnancy or childbirth. You’ll also find entries for different organs and anatomic locations where a “urinary” infection might strike: the bladder, kidneys, and urethra. However, you’ll need to find other codes once your provider pins down the specific UTI. Another important consideration when selecting the final diagnosis is whether the patient’s condition is chronic (persistent) or acute (sudden, short-term).

You might also need to report an additional code to identify the infectious agent (if applicable). If so, you’ll find the appropriate diagnoses in categories B95 through B97, which represent bacterial and viral infectious agents:

• B95 (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere)
• B96 (Other bacterial agents as the cause of diseases classified elsewhere)
• B97 (Viral agents as the cause of diseases classified elsewhere)

The bottom line: Look for more details in the documentation so you can specifically assign the right diagnosis code that reflects the type of UTI your physician treated.