ICD-10 Coding for Urinalysis Culture and Sensitivity(R31.1, N39.0)
Complete ICD-10-CM coding and documentation guide for Urinalysis Culture and Sensitivity. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Urinalysis Culture and Sensitivity
R30-R39Primary Range
Symptoms and signs involving the urinary system
This range includes codes for urinary symptoms that often necessitate urinalysis culture and sensitivity testing.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R31.1 | Asymptomatic hematuria | Use when urinalysis shows blood but the patient has no urinary symptoms. |
|
| N39.0 | Urinary tract infection, site not specified | Use when a UTI is diagnosed but the specific site is not identified. |
|
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 urinalysis culture and sensitivity
Essential facts and insights about Urinalysis Culture and Sensitivity
Primary ICD-10-CM Codes for urinalysis culture and sensitivity
Decision Criteria
clinical Criteria
- No urinary symptoms present
Applicable To
- Microscopic hematuria
Excludes
- Hematuria with symptoms (R31.0)
Clinical Validation Requirements
- Urinalysis showing red blood cells without symptoms
Code-Specific Risks
- Misclassification if symptoms are present
Coding Notes
- Ensure no symptoms are documented when using this code.
N39.0 - Urinary tract infection, site not specified
Use when a UTI is diagnosed but the specific site is not identified.
Applicable To
- UTI
Excludes
- Cystitis (N30.-)
- Pyelonephritis (N10)
Clinical Validation Requirements
- Symptoms such as dysuria, frequency, and urgency
- Positive urine culture
Coding Notes
Ensure symptoms and culture results are documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Urinalysis Culture and Sensitivity to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R31.1.
Impact
Clinical: May lead to inappropriate treatment, Regulatory: Non-compliance with documentation standards, Financial: Potential denial of claims
Mitigation Strategy
Use specific symptom descriptors, Link symptoms to test orders
Impact
Reimbursement: Denial of payment for 87088, Compliance: Non-compliance with CMS sequencing rules, Data Quality: Inaccurate representation of diagnostic process
Mitigation Strategy
Ensure 87086 is performed and documented before 87088.
Impact
Failure to document 87086 before 87088
Mitigation Strategy
Implement checklist to verify sequencing compliance
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 Urinalysis Culture and Sensitivity, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Urinalysis Culture and Sensitivity
Use these documentation templates to ensure complete and accurate documentation for Urinalysis Culture and Sensitivity. These templates include all required elements for proper coding and billing.
Initial UTI workup
Specialty: UrologyRequired Elements
- Chief complaint
- Physical examination findings
- Urinalysis results
- Culture orders
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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