ICD-10 Coding for Urinary Infection(N39.0, N30.00)
Complete ICD-10-CM coding and documentation guide for Urinary Infection. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Urinary Infection
N39.0-N39.9Primary Range
Other disorders of urinary system
This range includes codes for urinary tract infections, which are common and require specific documentation for accurate coding.
Cystitis
This range covers cystitis, a specific type of urinary infection affecting the bladder.
Acute tubulo-interstitial nephritis
This range includes acute pyelonephritis, a severe form of urinary infection affecting the kidneys.
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 the site of infection is not specified in the documentation. |
|
| N30.00 | Acute cystitis without hematuria | Use when the infection is identified as acute cystitis without hematuria. |
|
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 urinary infection
Essential facts and insights about Urinary Infection
Primary ICD-10-CM Codes for urinary infection
Decision Criteria
documentation Criteria
- Site of infection is not specified.
Clinical Validation Requirements
- Urine culture showing ≥100,000 CFU/mL
- Symptoms of dysuria, frequency, or urgency
Code-Specific Risks
- Risk of under-documentation if site is not specified.
Coding Notes
- Ensure documentation specifies symptoms and any lab results supporting the diagnosis.
N30.00 - Acute cystitis without hematuria
Use when the infection is identified as acute cystitis without hematuria.
Applicable To
- Acute cystitis NOS
Excludes
- Chronic cystitis (N30.2-)
Clinical Validation Requirements
- Urinalysis showing WBCs
- Symptoms of dysuria and urgency
Coding Notes
Document symptoms and lab results to support the diagnosis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Escherichia coli [E. coli] as the cause of diseases classified elsewhere
B96.2Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Urinary 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 inappropriate antibiotic selection., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims due to incomplete documentation.
Mitigation Strategy
Always document lab results showing the organism.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Impacts the accuracy of health records.
Mitigation Strategy
Ensure documentation specifies the site of infection if known.
Impact
Risk of audits due to missing site or organism details.
Mitigation Strategy
Implement thorough documentation practices including site and organism.
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 Urinary Infection, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Urinary Infection
Use these documentation templates to ensure complete and accurate documentation for Urinary Infection. These templates include all required elements for proper coding and billing.
Acute UTI in a non-pregnant adult
Specialty: Internal MedicineRequired Elements
- Symptoms: Dysuria, frequency, urgency
- Lab results: Urine culture, urinalysis
- Site of infection: Bladder, kidney
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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