Internal Medicine Coding Alert

Question: An elderly patient with a complaint of urinary tract burning and discomfort is seen in the office. The probable diagnoses are bladder infection or pyelonephritis. What is the correct ICD-9-CM diagnosis code?

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Answer: With ICD-9 coding, you can only code to the highest level of certainty. You should not code for suspected diseases unless you have verified their presence with testing or a definitive examination tool, or to rule out a specific disease. In this case, you could code 595.0 (acute cystitis) or even 595.9 (cystitis, unspecified). If you saw pus in the urine, 599.0 (urinary tract infection, unspecified) would be a good code. After testing for infectious organisms (assuming this is an infection), you will have to code the organismfor example, E. coli (041.4)and then report a cystitis code. If testing reveals a kidney as well as bladder infection, then there are several pyelonephritis codes (590.0-590.9), depending once again on the level of certainty. And remember, its always better to go to a five-digit code, if the information available supports it.