Ob-Gyn Coding Alert

Your ob-gyn bills these services frequently, so pinpoint the right codes.

When patients present to your ob-gyn practice with possible urinary tract infections (UTIs), your provider is likely to order a urine culture or perform urinalysis. To report the services accurately, you’ll need to pinpoint which ICD-10 codes describe your patient’s condition.

Fact:  Hundreds of signs, symptoms, test results, final diagnoses, and related conditions can lead to the need for urinalysis or urine culture, so your ob-gyn personnel should know how to spot diagnoses that make the grade or miss the mark to demonstrate medical necessity for one or more of the following ordered tests:

• 81000 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, ph, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy)
• 81001 (… automated, with microscopy)
• 81002 (… non-automated, without microscopy)
• 81003 (… automated, without microscopy)
• 81005 (Urinalysis; qualitative or semiquantitative, except immunoassays)
• 81007 (Urinalysis; bacteriuria screen, except by culture or dipstick)
• 81015 (Urinalysis; microscopic only)
• 87086 (Culture, bacterial; quantitative colony count, urine)
• 87088 (… with isolation and presumptive identification of each isolate, urine).

Read on to learn five tips for maneuvering UTI diagnosis coding.

Tip 1: Know When to Code Symptoms

Physicians often order or perform urinalysis when the patient presents with urinary symptoms that suggest a UTI, but before the patient has a known diagnosis. In those cases, you should code the signs and symptoms that the provider notes as the reason for the test, such as one of the following:

• R30.- (Pain associated with micturition)
• R31.- (Hematuria)
• R33.- (Retention of urine)
• R34.- (Anuria and oliguria)
• R35.- (Polyuria)
• R39.1- (Other difficulties with micturition).

You might also come across a test ordered for a patient with a history of UTIs, which you can code as Z87.440 (Personal history of urinary (tract) infections).

Caution: Most payers won’t cover screening urinalysis or urine culture ordered with a code such as Z01.419 (Encounter for gynecological examination (general) (routine) without abnormal findings) or Z11.2 (Encounter for screening for other bacterial diseases).

Tip 2: Specify UTI Site

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). To choose the appropriate diagnosis code, you’ll need to know the specific site and which ICD-10 code describes that type of UTI.

For the typical female patient presenting to the ob-gyn practice coders should look to the following groups or individual codes to quickly narrow down the diagnosis, according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California:

• N30.- (Cystitis)
• N34.- (Urethritis and urethral syndrome)
• N39.0 (Urinary tract infection, site not specified)

Johnson offers two important reminders for 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: Based on the ICD-10 note accompanying N30 and N34, you will need to use an additional code from B95-B97 to identify the infectious agent, if applicable. The infectious organism identification will depend on the results of a lab test such as a urine culture (87086, 87088) for presumptive identification or 87077 (Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate) for definitive identification.

Tip 3: Focus UTI in Pregnancy

If the patient with a UTI is pregnant, all bets are off for using any of the codes described in Tip 2. Instead, you should turn to one of the specific pregnancy UTI codes, such as the following:

• O23.4- (Unspecified infection of urinary tract in pregnancy)
• O03.38 (Urinary tract infection following incomplete spontaneous abortion)
• O03.88 (… following complete or unspecified spontaneous abortion)
• O04.88 (… following (induced) termination of pregnancy)
• O08.83 (… following an ectopic and molar pregnancy)
• O86.2- (… following delivery).

Tip 4: Track Urine Culture NCD

For urine culture codes 87086 and 87088, CMS has issued a National Coverage Determination (NCD) that specifies conditions for coverage and non-coverage of the tests.

Clinicians often order a urine culture in response to abnormal urinalysis findings indicated by ICD-10 codes such as R31.1 (Benign essential microscopic hematuria), R80.- (Proteinuria), or R82.71 (Bacteriuria). But physicians may also order urine culture as the initial test, with medical necessity indicated based on specific signs and symptoms such as those discussed in Tip 1.

Tip 5: Labs Must Follow Doctor’s Orders

Because labs must use the physician’s ordering diagnosis, ensure that your ob-gyn assigns an accurate ICD-10 code to ensure that everyone involved with the test bills the right code.