ICD-10 Coding for Escherichia coli Urinary Tract Infection(N39.0, A41.51, B96.20)
Complete ICD-10-CM coding and documentation guide for Escherichia coli Urinary Tract Infection. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Escherichia coli Urinary Tract Infection
N30-N39Primary Range
Diseases of the urinary system
This range includes codes for urinary tract infections, including those caused by E. coli.
Other bacterial sepsis
This range includes codes for sepsis, which can be a complication of E. coli UTI.
Bacterial and viral infectious agents
This range includes codes for identifying the infectious agent, such as E. coli, in infections.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N39.0 | Urinary tract infection, site not specified | Use when E. coli UTI is the primary reason for the encounter. |
|
| A41.51 | Sepsis due to Escherichia coli [E. coli] | Use when sepsis due to E. coli is the primary diagnosis. |
|
| B96.20 | Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere | Use as an additional code to specify E. coli as the causative agent. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for E. coli UTI
Essential facts and insights about Escherichia coli Urinary Tract Infection
Primary ICD-10-CM Codes for escherichia coli urinary tract infection
Decision Criteria
clinical Criteria
- Presence of UTI symptoms and positive urine culture for E. coli.
documentation Criteria
- Provider documentation must explicitly state E. coli as the cause.
Applicable To
- UTI
Excludes
- Asymptomatic bacteriuria (R82.71)
Clinical Validation Requirements
- Urine culture showing ≥10⁵ CFU/mL of E. coli
- Symptoms such as dysuria, frequency, urgency
Code-Specific Risks
- Ensure provider documentation explicitly links E. coli to the UTI.
Coding Notes
- Ensure documentation specifies 'E. coli UTI' for accurate coding.
A41.51 - Sepsis due to Escherichia coli [E. coli]
Use when sepsis due to E. coli is the primary diagnosis.
Applicable To
- Sepsis due to E. coli
Clinical Validation Requirements
- Blood cultures positive for E. coli
- SIRS criteria met (e.g., fever, tachycardia)
Coding Notes
Sepsis must be documented as present on admission if coded as primary.
B96.20 - Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere
Use as an additional code to specify E. coli as the causative agent.
Applicable To
- E. coli as causative agent
Clinical Validation Requirements
- Provider documentation linking E. coli to the infection
Coding Notes
Requires explicit provider documentation linking E. coli to the condition.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Asymptomatic bacteriuria
R82.71Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Escherichia coli Urinary Tract Infection to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N39.0.
Impact
Clinical: May lead to incorrect treatment plans., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to incorrect coding.
Mitigation Strategy
Always verify with provider documentation., Use queries to confirm causative agent if not documented.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data affecting patient records.
Mitigation Strategy
Query provider to confirm E. coli as causative for UTI.
Impact
Reimbursement: Incorrect DRG assignment affecting reimbursement., Compliance: Potential audit risk for incorrect sequencing., Data Quality: Misleading clinical data on patient condition.
Mitigation Strategy
Ensure sepsis is coded as primary if present on admission.
Impact
Failure to sequence sepsis as primary when present on admission.
Mitigation Strategy
Review admission notes for sepsis criteria and sequence codes accordingly.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Escherichia coli Urinary Tract Infection, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Escherichia coli Urinary Tract Infection
Use these documentation templates to ensure complete and accurate documentation for Escherichia coli Urinary Tract Infection. These templates include all required elements for proper coding and billing.
Uncomplicated outpatient UTI
Specialty: Primary CareRequired Elements
- Patient symptoms
- Urine culture results
- Provider documentation linking E. coli to UTI
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Sepsis secondary to UTI
Specialty: Infectious DiseaseRequired Elements
- Sepsis symptoms
- Blood and urine culture results
- Provider documentation of sepsis due to E. coli
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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