Urology Coding Alert

Hit: Check whether other anatomic sites are involved.

While a urinary tract infection (UTI) might be one of the most common conditions that a urologist treats, that doesn’t mean you can make assumptions about reporting the care. Selecting the correct diagnosis code is paramount, especially when symptoms that appeared to point to a UTI actually lead elsewhere.

Now follow our experts’ top tips for confirming that the condition is a UTI and selecting the correct diagnosis.

Tip 1: Pinpoint the Associated Symptoms

Starting point: The first ICD-10-CM code that pops up when you search for “infection/urinary (tract)” is N39.0 (Urinary tract infection, site not specified). But when you dig further into the listing, you’ll find codes for UTIs that are associated with conditions such as pregnancy or childbirth. You’ll also find entries for different organs and anatomic locations where a “urinary” infection might strike: the bladder, kidneys, and urethra.

Because there are a number of symptoms that might point to UTI but aren’t UTIs themselves, you’ll want to consider every symptom that the physician documented. Some signs and symptoms are consistent with a UTI, such as:

• R30.- (Pain associated with micturition)
• R33.- (Retention of urine)
• R35.- (Polyuria)
• R39.1- (Other difficulties with micturition)

Documentation might also show that the patient has a history of UTI. If so, you’ll want to include diagnosis Z87.440 (Personal history of urinary (tract) infections) on your claim.

All of these could, after testing, result in a definitive diagnosis. But you’ll need to find other codes once your provider pins down the specific UTI.

Tip 2: Explore Other Sites and Names

As noted above, patients might have UTI symptoms that stem from other anatomic sites instead of the urinary tract. If you learn this is the case, the condition goes by a different name based on the specific site of the urinary infection: the kidneys (pyelonephritis), the bladder (cystitis), or the urethra (urethritis).

Because of the specific locations within the urinary tract, you’ll also find different diagnostic codes for infection in these locations:

• N10 (Acute pyelonephritis)
• N30.- (Cystitis)
• N34.- (Urethritis and urethral syndrome)
• 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.

Tip 3: Note Chronic or Acute

Another important consideration when selecting the final diagnosis is whether the patient’s condition is chronic (persistent) or acute (sudden, short-term).

Example: 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).

You might also need to report an additional code to identify the infectious agent (if applicable), reminds Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook. If so, you’ll find the appropriate diagnoses in categories B95 through B97, which represent bacterial and viral infectious agents:

• B95 (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere)
• B96 (Other bacterial agents as the cause of diseases classified elsewhere)
• B97 (Viral agents as the cause of diseases classified elsewhere)

Tip 3: Check for Hematuria

One last detail you’ll need to check in the physician’s documentation is whether your urologist notes that the patient also has hematuria. If the patient does, your coding will change.

Review the table below to see the ICD-10-CM options you may wish to list.

Full circle: In the end, however, Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Michigan, reminds coders that unless they are dealing with a pregnant patient or a neonate  “most cases often code back to N39.0.”

Remember, however, that diagnosis N39.0 is an unspecified code. Ferragamo warns that many such diagnostic codes often lead to denials of claims by carriers when only unspecified ICD-10-CM diagnostic codes are reported. The better your provider’s documentation is, the better your chances at adequate reimbursement will be.