ICD 10 Coding Alert

Question: A provider documents that a patient has delirium due to an acute urinary tract infection (UTI) affecting the bladder. Do I report both the delirium and the UTI?

Kansas Subscriber

Answer: In this situation, you have several diagnoses to navigate. Since the documentation mentions delirium first, look to F05 (Delirium due to known physiological condition), which has a Code first note instructing you to specify the underlying physiological condition first. Still, you’ll want to include the F05 code in your diagnosis coding.

With your physician diagnosing an acute UTI in the bladder, look for the code for cystitis, which would lead you to N30.0- (Acute cystitis).

Based on the ICD-10-CM note accompanying N30, you will need to use an additional code from B95.- (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere) through B97.- (Viral agents as the cause of diseases classified elsewhere) to identify the infectious agent, if applicable.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC