Outpatient Facility Coding Alert
Distinguish When to Code a Diagnosis vs. a Symptom
Question: The provider documented the following results: “positive for UTI associated organisms and antibiotic resistance detected.” What ICD-10 codes would you assign to this?
Minnesota Subscriber
Answer: You will need to know whether there is a confirmed diagnosis here. As per guidelines, we can only code a confirmed diagnosis. In case if it is not given, you may go ahead and codethe symptoms instead. Remember that you may only code a symptom with a confirmed diagnosis when the symptom is not associated with the confirmed diagnosis. As per current documentation you have provided, you may report codes N39.0 (Urinary tract infection, site not specified) and Z16.20 (Resistance to unspecified antibiotic).
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