Internal Medicine Coding Alert

Don’t forget to additionally report causative organism.

When reporting a diagnosis of urinary tract infection (UTI), you’ll have to look at documentation to see if your clinician has identified the site of infection to enable you to zero in on the right code that you will have to select. If you are reporting acute cystitis, you’ll have to look deeper into documentation to see if your clinician has mentioned hematuria, as this will affect the code choice in ICD-10.

ICD-9: When your physician diagnoses a patient with a urinary tract infection of an unspecified site, you can report the diagnosis with the ICD-9 code, 599.0 (Urinary tract infection, site not specified). Typically, this is what you will report when your internist does not mention whether the patient has an upper or a lower urinary tract infection. This code excludes candidiasis of the urinary tract (112.2) and UTI of newborn (771.82).

If your internist diagnoses the patient with acute cystitis, which is a urinary tract infection of the lower tract, you will report it with the ICD-9 code, 595.0 (Acute cystitis), which excludes trigonitis (595.3). In other situations, your clinician may find that a patient has acute pyelonephritis, which is an infection of the upper tract. You’ll have to report this with another ICD-9 code, either 590.10 (Acute pyelonephritis without lesion of renal medullary necrosis) or 590.11 (Acute pyelonephritis with lesion of renal medullary necrosis).

Note: When reporting any of the above mentioned diagnoses with their respective ICD-9 codes, you will have to remember to report an additional code to identify the causative organism for the condition. Suppose the condition has been determined by lab tests to have been caused by Escherichia coli (E. coli), you report from one of the ICD-9 codes from the range, 041.41-041.49, depending on the type of E. coli (Shiga toxin-producing strains or Non-Shiga toxin producing strains) that has been identified.

ICD-10: When you begin using ICD-10 codes after Oct. 1, 2015, you will have to report N39.0 (Urinary tract infection, site not specified) as a crosswalk to the ICD-9 code 599.0. You will use this code to report a diagnosis of unspecified site (when your provider has not confirmed if it is upper tract or lower tract) urinary tract infection. As with ICD-9 codes, you cannot use N39.0 if your clinician diagnoses a urinary tract infection in a neonate as you have a separate code to report this. You use P39.3 (Neonatal urinary tract infection) to report a neonatal urinary tract infection. Also, you cannot use N39.0 for a diagnosis of candidiasis of the urinary tract. You use B37.4- to report this.

For a diagnosis of acute cystitis, you will have to begin using N30.0- (Acute cystitis) instead of 595.0. However, you have to delve into documentation to see if your clinician has mentioned the presence of blood in the urine in his findings. You need to do this as you have two reporting options for acute cystitis based on the presence or absence of hematuria:

• N30.00 (Acute cystitis without hematuria) 
• N30.01 (Acute cystitis with hematuria)

But, if your clinician diagnoses the patient with an upper urinary tract infection such as pyelonephritis, you will have to switch to using N10 (Acute tubulo-interstitial nephritis) instead of 590.10. Even though you do not have the term “pyelonephritis” in the descriptor to N10, “acute pyelonephritis” is listed as a term under this code, so you will have to use this diagnosis code to report this condition. You also use N10 for other conditions such as acute infectious interstitial nephritis, acute pyelitis, hemoglobin nephrosis, and myoglobin nephrosis.

Reminder: As with ICD-9 coding, your reporting for a diagnosis of UTI will not be complete if you do not also report the infectious organism that has caused the condition. When using ICD-10, look for options from B95-B97 to correctly report the organism that has been identified through lab test as the agent responsible for the UTI.

Focus on These Basics Briefly

Documentation spotlight: Your clinician will arrive at a diagnosis of UTI based on a complete history and an evaluation of the person’s signs and symptoms along with ordering or performing of some diagnostic lab tests.

Some of the findings that your clinician will find in a patient with UTI will include dysuria, urgency to urinate frequently, pain in the lower abdominal area, and a feeling of fullness of the bladder. Your clinician might also note the presence of blood in the urine.

Upon examination, your physician might note tenderness over the suprapubic or costovertebral angle. Your clinician might also note the presence of fever, chills, or malaise, which is usually a sign of upper tract urinary infection. Your clinician might also note the presence of clammy extremities, tachycardia, and other signs of dehydration.

Tests: Some of the lab tests that your clinician might order when he suspects a diagnosis of UTI will include urinalysis, dipstick evaluation, microscopic evaluation of urine, nitrate tests, and urine culture.

Based on signs and symptoms and results of lab tests, your clinician will be able to confirm a diagnosis of UTI.