Wiki Does N30.00/N30.01 Acute Cystitis with/without Hematuria refer to GROSS hematuria?

[OregonCindi]

I'm researching the clinical definition of Cystitis with and without Hematuria because one of my (family practice) providers feels it refers to gross hematuria, rather than from a lab result. The provider selected "Acute cystitis without hematuria" because the patient didn't note any blood in the urine, but the UA result in the chart note says 2+ positive for occult blood. If I code N30.00, will that be supported, when we have the lab result in the chart note?

Thank you for any input!

Cindi Williams, CPC

 

[thomas7331]

Code choices are based solely on provider assessments of the patient - they cannot be assigned from clinical criteria. The clinical definition might be useful for the provider in helping to determine how to accurately diagnose the patient, but from a coding point of view, the ICD-10 choice must be based on the provider's diagnostic statement, not on a clinical interpretation of the labs. In other words, if the provider chooses to document a diagnosis of acute cystitis but does not diagnose the patient as having hematuria, the coder has no choice but to assign N30.00.

I find it helpful to advise providers that when an ICD-10 definition states 'without', that is the equivalent of 'without mention of' or 'without documentation of' the condition. 'Without' does not mean that the patient does not have hematuria, it only means that the hematuria has not been documented as being present. With this understanding, if the provider feels that the condition is uncertain, the correct code choice would be the 'without' code as the default.