ICD-10 Coding for Urinary Tract Infection without Hematuria(N30.00, N39.0)
Complete ICD-10-CM coding and documentation guide for Urinary Tract Infection without Hematuria. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Urinary Tract Infection without Hematuria
N30-N39Primary Range
Diseases of the urinary system
This range includes codes for urinary tract infections, including cystitis and unspecified UTIs.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N30.00 | Acute cystitis without hematuria | Use when documentation specifies acute cystitis without hematuria. |
|
| N39.0 | Urinary tract infection, site not specified | Use when the site of the UTI is not specified. |
|
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 UTI without hematuria
Essential facts and insights about Urinary Tract Infection without Hematuria
Primary ICD-10-CM Codes for urinary tract infection without hematuria
Decision Criteria
clinical Criteria
- Presence of dysuria, urgency, and suprapubic pain without hematuria.
documentation Criteria
- Explicit mention of 'acute cystitis without hematuria'.
Applicable To
- Bladder infection without blood in urine
Excludes
- Acute cystitis with hematuria (N30.01)
Clinical Validation Requirements
- Urinalysis showing WBC >10/hpf and RBC <3/hpf
- Positive urine culture with ≥10³ CFU/mL of a uropathogen
Code-Specific Risks
- Risk of denial if hematuria is present but not documented.
Coding Notes
- Ensure documentation specifies the absence of hematuria.
N39.0 - Urinary tract infection, site not specified
Use when the site of the UTI is not specified.
Applicable To
- UTI NOS
Excludes
- Cystitis (N30.-)
Clinical Validation Requirements
- Symptoms of UTI without specific site localization.
Coding Notes
Avoid using if specific site is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Dysuria
R30.0Differential 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 Tract Infection without Hematuria to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N30.00.
Impact
Clinical: May lead to incorrect treatment decisions., Regulatory: Non-compliance with coding guidelines., Financial: Potential for claim denials.
Mitigation Strategy
Always document presence or absence of hematuria.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding specificity requirements., Data Quality: Impacts the accuracy of clinical data.
Mitigation Strategy
Ensure documentation specifies the site of infection to use N30.00.
Impact
Using unspecified codes when specific codes are available.
Mitigation Strategy
Ensure documentation supports the most specific code.
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 Tract Infection without Hematuria, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Urinary Tract Infection without Hematuria
Use these documentation templates to ensure complete and accurate documentation for Urinary Tract Infection without Hematuria. These templates include all required elements for proper coding and billing.
Primary Care Visit for UTI Symptoms
Specialty: Primary CareRequired Elements
- Symptoms: Dysuria, urgency, suprapubic pain
- Urinalysis results: WBC >10/hpf, RBC <3/hpf
- Culture results: Positive for specific organism
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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