Urology Coding Alert

Question: If a patient has urinary symptoms, our physician orders a dip stick and prescribes antibiotics. The culture is pending. He documents a urinary tract infection (UTI) and assigns diagnosis code N39.0. Is it appropriate to code the encounter as "signs and symptoms" until we receive the culture results?

Virginia Subscriber

Answer: If the provider diagnosis an infection or infective condition based on the presenting symptoms, then code that diagnosis.

Some coders recommend that you wait until you have lab results confirming a UTI before you file a claim with that diagnosis. In this type of situation, however, other coders assert that you do not need a culture report to code a UTI – just realize that you will not have an organism to report. This is one instance where an unspecified code choice is appropriate. So, if the provider states that the patient has a UTI, submit diagnosis N39.0 (Urinary tract infection, site not specified). If he states the UTI is "possible," then assign a diagnosis based on the symptoms.

Discuss the case with your physician and review the documentation to help guide your decision for timing the claim submission.