ICD-10 Coding for Personal History of Urinary Tract Infection(Z87.440)
Complete ICD-10-CM coding and documentation guide for Personal History of 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 Personal History of Urinary Tract Infection
Key Information: ICD-10 code for personal history of urinary tract infection
Essential facts and insights about Personal History of Urinary Tract Infection
Primary ICD-10-CM Code for personal history of urinary tract infection
Decision Criteria
clinical Criteria
- Patient has a documented history of UTIs with no current symptoms.
documentation Criteria
- Provider notes must include terms like 'resolved' or 'history of'.
Applicable To
- Resolved urinary tract infections
- Past urinary tract infections
Clinical Validation Requirements
- Documented history of resolved UTIs
- No current symptoms of UTI
Code-Specific Risks
- Incorrectly coding active UTIs as history
- Using without documented history
Coding Notes
- Ensure documentation clearly states the UTI is resolved and part of the patient's history.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z09Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Personal History of Urinary Tract Infection to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z87.440.
Impact
Clinical: Misleading clinical history, Regulatory: Non-compliance with coding standards, Financial: Potential for denied claims
Mitigation Strategy
Ensure detailed history is documented, Clarify with provider if necessary
Impact
Reimbursement: May lead to incorrect billing and potential audits., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Ensure documentation specifies past resolved episodes.
Impact
Using Z87.440 without proper documentation of resolved UTIs.
Mitigation Strategy
Ensure all history codes are supported by clear documentation.
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 Personal History of Urinary Tract Infection, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Personal History of Urinary Tract Infection
Use these documentation templates to ensure complete and accurate documentation for Personal History of Urinary Tract Infection. These templates include all required elements for proper coding and billing.
Annual Exam with History of UTIs
Specialty: Primary CareRequired Elements
- Patient history
- Resolution of past UTIs
- Current symptom status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Personal History of Urinary Tract Infection? Ask your questions below.