Urology Coding Alert

For patients under 28 days of age with a UTI, report P39.3.

Reporting the correct code for a urinary tract infection (UTI) can be tricky. For example, you need to know when it’s appropriate to use the site not specified code, as well as when you can report the signs and symptoms.

Follow five tips to make sure you report the correct UTI code in your practice.

Tip 1: Report N39.0 With Caution

Although N39.0 (Urinary tract infection, site not specified) may be an attractive and the obvious choice to the provider, there are a couple of issues with this code. First, the lack of specificity in the code presents a real problem for reimbursement because the industry is moving toward diagnostic-based reimbursement, so the use of unspecified codes is becoming less accepted. Also, diagnosing a UTI without a culture is becoming a thing of the past.

Second, code N39.0 contains a note telling you to use an additional code from category B95- (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere) through category B97- (Viral agents as the cause of diseases classified elsewhere) to identify the infectious agent, if applicable, after your provider has administered a test. This could be problematic because your provider probably won’t have the in-house resources to identify the infectious agent to meet coding guidelines. So, you should code based on signs and symptoms if the provider is unable to meet the coding guidelines requiring identification of an infectious agent.

Tip 2: Turn to Signs and Symptoms in Some Cases

While your provider is in the process of forming a formal UTI diagnosis, you might use a signs and symptoms code from Chapter 18. Even though these signs and symptoms are also unspecified, they are still the best codes to use in the absence of a definitive diagnosis.

Depending on provider documentation, you could use one of the following before your provider can provide the specific diagnosis:

• R30.- (Pain associated with micturition)
• R32 (Unspecified urinary incontinence)
• R33.- (Retention of urine)
• R35.- (Polyuria)
• R39.1- (Other difficulties with micturition)
• R82.81 (Pyuria)

But once your provider pins down the specific UTI, you will move to other, more specific codes.

Tip 3: Pinpoint UTI’s Location and Severity

Once your provider makes a formal UTI diagnosis, they should use the specific site if known. That means narrowing the diagnosis

For the N30.- codes, you will also have to pay close attention to your provider’s note to see if the patient has been diagnosed with acute (sudden) or chronic (persistent) cystitis. If your physician documents the patient with acute cystitis, you’ll report N30.0- (Acute cystitis); but if the documentation states chronic cystitis, you’ll report N30.1- (Interstitial cystitis (chronic)) or N30.2- (Other chronic cystitis).

Tip 4: Remember to Include Associated Diagnoses

These UTI codes also come with “Use additional code” instructions that tell you to use a code from B95- through B97- range if a test ordered by your provider shows that a bacterium or virus is the cause of the condition. So, you should keep these additional common bacterium or virus codes handy:

• B96.2- (Escherichia coli [E. coli] as the cause of diseases classified elsewhere)
• B96.1 (Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere)
• B96.4 (Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere)
• B95.2 (Enterococcus as the cause of diseases classified elsewhere)
• B95.7 (Other staphylococcus as the cause of diseases classified elsewhere)

Tip 5: Some UTI Codes Are Elsewhere

UTIs during and after pregnancy: Organisms causing UTI in pregnancy are the same uropathogens which commonly cause UTI in non-pregnant patients, but your coding for pregnant patients will be a little different.

Most often, you’ll use a code from the O23.- (Infections of genitourinary tract in pregnancy) group, which contains a “Use additional code” instruction for bacterial etiology coded to B95.- or B96.-. But you’ll use a code from O86.2- (Urinary tract infection following delivery) for patients diagnosed with a UTI after giving birth. And you’ll also find pregnancy-related UTI codes among the Pregnancy with abortive outcome (O00-O08) codes should your provider document the condition. For example, you may report O03.38 in the case of a UTI following incomplete spontaneous abortion.

UTIs in neonates: If the patient is under 28 days of age and has a UTI, you should report P39.3 (Neonatal urinary tract infection).

UTIs in patients with stomas: You’ll code a patient who has a urinary stoma (an opening in the body to remove urine after diversionary surgery) with N99.521 (Infection of incontinent external stoma of urinary tract) or N99.531 (Infection of continent stoma of urinary tract). But before using one of these codes, you will need to make sure that your provider has documented and confirmed a cause-and-effect relationship between the procedure and the condition.

Patients with a history of UTIs: You’ll code this with Z87.440 (Personal history of urinary (tract) infections).

Don’t miss: “As you can see, a diagnosis of a urinary tract infection may include one specific diagnostic ICD-10-CM code to several codes to clearly define the clinical scenario at hand,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook. “Use all diagnostic codes known at the time of the encounter but remember only one code of all reported will usually allow payment of the service.”