Urology Coding Alert

Question: A patient has a recurrent urinary tract infection. The diagnoses given are N30.21, R35.0, R32, and R39.15. According to the documentation, the patient did have a full round of Cipro and nitrofurantoin at home for self-treatment, and if she has another UTI, she will take the Cipro. If things fail, then she will take the nitrofurantoin. Should I report N30.21 in this case or Z87.440? Also, should I report an antibiotic therapy code?

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Answer: You should report a urinary tract infection (UTI) without further specificity using N39.0 (Urinary tract infection, site not specified), not N30.21 (Other chronic cystitis with hematuria). Do not report Z87.440 (Personal history of urinary (tract) infections) based simply on the term “recurrent” unless your provider has also documented a history of UTIs in the past. However, without being able to see the record itself though, it’s difficult to say if any of these codes are correct or not.

Per the ICD-10-CM guidelines, you would not normally report the three symptom codes in addition to the UTI diagnosis since they are symptoms that are routinely associated with that condition. Therefore, R35.0 (Frequency of micturition), R32 (Unspecified urinary incontinence), and R39.15 (Urgency of urination) would not be correct coding for this case.