ED Coding and Reimbursement Alert

Question: Which diagnosis should we report for a urinary tract infection (UTI) of a male patient?

Utah Subscriber

Answer: Fortunately, the urinary tract infection codes aren’t necessarily differentiated by gender, so you’ll need to find the most accurate code based on the documentation.

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, which would immediately be ruled out for a male patient. 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.