MDS Alert

Your search for the correct code may be more involved than you hoped.

If you’re still getting comfortable with the idiosyncrasies of ICD-10, you may feel relieved to see N39.0 (Urinary tract infection, site not specified). It’s the first code listed in the ICD-10-CM alphabetic index when you look up Infection/urinary (tract). However, that doesn’t mean your search for the correct urinary tract infection (UTI) code should end there.

Look through the listing, and you’ll find codes for UTIs associated with conditions that you probably won’t find in a long-term care setting (like pregnancy or birth), but you’ll also find entries for different organs and various locations a “urinary” infection might strike, such as the bladder (see Cystitis), the kidneys (see Infection, kidney), and the urethra (see Urethritis).

Fear not: You don’t have to go off on a wild ICD-10-CM goose chase. Take these expert hints and keep your UTI coding specific and accurate.

Remember: Coding and documenting a UTI in the long-term care setting requires following specific guidance set out by the Resident Assessment Instrument (RAI) Manual, which you can find on page I-12:

• “It was determined that the resident had a UTI using evidence-based criteria such as McGeer, NHSN, or Loeb in the last 30 days, AND
• “A physician documented UTI diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days.”

So, if you’re sure the resident in question meets these requirements, read on about how to determine the correct ICD-10 code(s).

Hint 1: Be Certain of the Diagnosis

Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, reminds coders that there are a number of symptoms that may point to UTI but that aren’t UTIs in themselves.

So, looking at the clinical record, you may see notes of signs and symptoms that are consistent with a UTI, such as:

• R30.- —  Pain associated with micturition
• R33.- — Retention of urine
• R35.- — Polyuria
• R39.1- — Other difficulties with micturition.

You might also come across a patient with a history of UTIs, which you can code with Z87.440 (Personal history of urinary (tract) infections). All of these could, after testing, result in a definitive diagnosis. But you’ll need to find other codes once your provider pins down the specific UTI.

Hint 2: Know the Different Location and Names

Complicating the situation, UTIs go by different names, depending on their location in the body. They typically occur in the kidneys (pyelonephritis), the bladder (cystitis), or the urethra (urethritis). In addition to N39.0, Johnson suggests coders look to the following groups or individual codes to quickly narrow down the diagnosis:

• N10 — Acute pyelonephritis
• N30.- — Cystitis
• N34.- — Urethritis and urethral syndrome
• N99.521 — Infection of incontinent external stoma of urinary tract
• N99.531 — Infection of continent stoma of urinary tract

Johnson offers three important reminders that you will need to remember when choosing the correct code from this list. First, you need to remember the difference between acute (sudden) and chronic (persistent). For instance, if the patient has acute cystitis, you’ll report N30.0- (Acute cystitis), but if the patient’s cystitis is chronic, you’ll report N30.1- (Interstitial cystitis (chronic)) or N30.2- (Other chronic cystitis).

Second, following the note accompanying N10, you will need to use an additional code from B95-B97 to identify the infectious agent, if applicable, after your provider has administered a test.

Third, regarding the N99 codes, Johnson explains that, because they are complication codes, “they require physician documentation and confirmation of a cause-and-effect relationship between any specified procedure and the complicated condition.”

In the end, however, Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Michigan, reminds coders that unless they are dealing with a pregnant patient or a neonate — which, again, is pretty unlikely in a long-term care setting — “everything codes back to N39.0.”