Pediatric Coding Alert

Question: Our pediatrician recently saw a patient who came in because she was grabbing her privates and her mother thought she had a urinary tract infection (UTI). Our pediatrician's evaluation in the office was normal, but she did demonstrate the "grabbing" in front of the doctor and the nurse. Can you recommend a diagnosis code I can use to bill for this? The patient was not having any pain.

Texas Subscriber

Answer: If she is a non-toilet trained toddler, she may be grabbing just prior to urination as she becomes aware of her bodily needs. If that is the case, you could report 788.63 (Urgency of urination) or 788.99 (Other symptoms involving urinary system).

If those circumstances don't fit your patient, you might have to resort to the "worried well" code V65.5 (Person with feared complaint in whom no diagnosis was made). Make sure the physician thoroughly documents the tests and evaluation he performed to determine whether or not the patient had a UTI, as well as a description of the patient's symptoms and findings.