Primary Care Coding Alert

Question: I’ve been using N39.0 for urinary tract infections (UTIs), but it was recently rejected. What code should I be using?

Kansas Subscriber

Answer: Reimbursement is sometimes a challenge with N39.0 (Urinary tract infection, site not specified) because of the lack of specificity. Since diagnosing a UTI without a culture isn’t common practice, and there’s a Use additional code note listed with N39.0 instructing coders to identify the infectious agent, it’s sometimes best to code to signs and symptoms when the other information is not available (for example, when the test results haven’t come back, and the provider is unable to identify the infectious agent or specific site of the UTI).

In cases where the infectious agent is unknown or the physician doesn’t specify the site of the UTI, and depending on the provider’s documentation, consider one or more of the following codes:

• R30.- (Pain associated with micturition)
• R32 (Unspecified urinary incontinence)
• R33.- (Retention of urine)
• R82.81 (Pyuria)

If the patient is pregnant however, you’ll potentially code the UTI a little differently. Usually, you’ll select a code from the O23.- (Infections of genitourinary tract in pregnancy) group, but be on the lookout for a Use additional code instruction to identify the organism here also. If the patient was diagnosed with a UTI after giving birth, however, O86.2.- (Urinary tract infection following delivery) is appropriate. Again, you will need to use an additional code to identify the infectious organism. Use O08.83 (Urinary tract infection following an ectopic and molar pregnancy) in addition to a code from O00-O02 if you need to report a UTI following an ectopic or molar pregnancy. For a UTI following a spontaneous abortion (O03.-), induced termination of pregnancy (O04.-), or failed attempted termination of pregnancy (O07.-), consider using the appropriate UTI code within the corresponding family, such as O07.38 (Urinary tract infection following failed attempted termination of pregnancy).

You’ll also need to know the bacterial etiology from B95.- (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere) or B96.- (Other bacterial agents as the cause of diseases classified elsewhere). If the UTI occurred during pregnancy and therefore calls for O23.- the Use additional code note directs you to identify the organism that caused the infection. If the UTI occurred following delivery, therefore calling for the use of O86.2.-, the Use additional code note includes a third possible infectious agent from which to choose, B97.- (Viral agents as the cause of diseases classified elsewhere).