Primary Care Coding Alert

Question: Our physician diagnosed a patient with a urinary tract infection (UTI), but choosing the right UTI ICD-10 code has been challenging for me. How can I make sure I’m picking the most appropriate code?

Answer: This can be tricky, because 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. Choices you have include the following:

• N10 (Acute pyelonephritis)
• N30.- (Cystitis)
• N34.- (Urethritis and urethral syndrome)
• N39.0 (Urinary tract infection, site not specified)
• N99.521 (Infection of incontinent external stoma of urinary tract)
• N99.531 (Infection of continent stoma of urinary tract)

Pay attention: Because the N99 codes are complication codes, they require physician documentation and confirmation of a cause-and-effect relationship between any specified procedure and the complicated condition.

Here are two helpful tips for how to choose the appropriate option from the above-mentioned UTI codes:

1: Remember the difference between acute (sudden, short-term) 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). Also remember that the physician is the one who can decide whether any condition is acute or chronic.

2: Based on the ICD-10 note accompanying N10, N30, N34, and N39.0, you will need to use an additional code from B95.- (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere) through B97.- (Viral agents as the cause of diseases classified elsewhere) 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.