ICD 10 Coding Alert

Hint: A UTI may implicate the bladder or kidneys or urethra.

Even though an ICD-10 code, N39.0 (Urinary tract infection, site not specified), exists for urinary tract infections (UTI), landing on the right code for a UTI diagnosis is not necessarily clearcut. It’s always important to remember that specificity is crucial for accurate coding, and UTIs are no exception.

Try these strategies for landing on the most accurate code for a UTI diagnosis.

Know Why an Unspecified UTI Code May Be Problematic

“N39.0 may be attractive and the obvious choice to the provider. However, there are a couple of issues with this,” says Donna Walaszek, CCS-P, billing manager, credentialing/ coding specialist for Northampton Area Pediatrics LLP in Northampton, Massachusetts.

First, the lack of specificity in the code presents a real problem for reimbursement because “the industry is moving toward diagnostic-based reimbursement, so the use of unspecified codes is becoming less accepted; and diagnosing a UTI without a culture is becoming a thing of the past,” Walaszek cautions.

Second, N39.0 contains a note telling you to use an additional code from B95-B97 to identify the infectious agent, if applicable, after your provider has administered a test. This becomes a problem because “a provider probably won’t have the in-house resources to identify the infectious agent to meet coding guidelines. As such, I recommend coding based on signs and symptoms if the provider is unable to meet the coding guidelines requiring identification of an infectious agent,” Walaszek advises.

Look to Signs and Symptoms Code in Some Circumstances

“While a provider is in the process of forming a formal UTI diagnosis, you might use a signs and symptoms code from Chapter 18. Even though these signs and symptoms are also unspecified, they are still the best codes to use in the absence of a definitive diagnosis,” suggests JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis.

Depending on provider documentation, you could use one of the following before your provider can provide the specific diagnosis:

• R30.- (Pain associated with micturition)
• R32 (Unspecified urinary incontinence)
• R33.- (Retention of urine)
• R35.- (Polyuria)
• R39.1- (Other difficulties with micturition)
• R82.81 (Pyuria)

But once your provider pins down the specific UTI, you will move to other, more specific codes.

Pinpoint Location and Severity

“Once the provider makes a formal UTI diagnosis, the provider should use the specific site if known,” Wolf advises. That means narrowing the diagnosis based on the location of the infection, as the table below shows:

For the N30.- codes, you will also have to pay close attention to your provider’s note to see if the patient has been diagnosed with acute (sudden) or chronic (persistent) cystitis. If your physician documents the patient with acute cystitis, you’ll report N30.0- (Acute cystitis); but if the documentation states chronic cystitis, you’ll report N30.1- (Interstitial cystitis (chronic)) or N30.2- (Other chronic cystitis).

Don’t Forget to Consider Associated Diagnoses

These UTI codes also come with “Use additional code” instructions that tell you to use a code from the B95-B97 (Bacterial and viral infectious agents) if a test ordered by your provider shows that a bacterium or virus is the cause of the condition. So, you should keep these additional common bacterium or virus codes handy:

• B96.2- (Escherichia coli [E. coli] as the cause of diseases classified elsewhere)
• B96.1 (Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere)
• B96.4 (Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere)
• B95.2 (Enterococcus as the cause of diseases classified elsewhere)
• B95.7 (Other staphylococcus as the cause of diseases classified elsewhere)

Some UTI Codes Are Elsewhere

UTIs during and after pregnancy: “Organisms causing UTI in pregnancy are the same uropathogens which commonly cause UTI in non-pregnant patients” (www.ncbi.nlm.nih.gov/books/NBK537047/). But your coding for pregnant patients will be a little different.

Most often, you’ll use a code from the O23.- (Infections of genitourinary tract in pregnancy) group, which contains a “Use additional code” instruction for bacterial etiology coded to B95.- or B96.-. But you’ll use a code from O86.2- (Urinary tract infection following delivery) for patients diagnosed with a UTI after giving birth. And you’ll also find pregnancy-related UTI codes among the Pregnancy with abortive outcome (O00-O08) codes should your provider document the condition. For example, you may report O03.38 in the case of a UTI following incomplete spontaneous abortion.

UTIs in neonates: “If the patient is under 28 days of age and has a UTI, you will need to use P39.3 [Neonatal urinary tract infection],” Wolf reminds coders.

UTIs in patients with stomas: You’ll code a patient who has a stoma (an opening in the body to remove bodily waste following surgery) with N99.521 (Infection of incontinent external stoma of urinary tract) or N99.531 (Infection of continent stoma of urinary tract). But before using one of these codes, you will need to make sure that your provider has documented and confirmed a cause-and-effect relationship between the procedure and the condition.

Patients with a history of UTIs: You’ll code this with Z87.440 (Personal history of urinary (tract) infections).