ICD-10 Coding for Urine Culture(N39.0, R31.1)
Complete ICD-10-CM coding and documentation guide for Urine Culture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Urine Culture
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 a patient presents with UTI symptoms and a positive urine culture. |
|
| R31.1 | Benign microscopic hematuria | Use when hematuria is detected without infection. |
|
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 urine culture
Essential facts and insights about Urine Culture
Primary ICD-10-CM Codes for urine culture
Decision Criteria
clinical Criteria
- Presence of dysuria and positive culture
Applicable To
- UTI
Excludes
- Asymptomatic bacteriuria (R82.71)
Clinical Validation Requirements
- Dysuria
- Positive urine culture with ≥10^5 CFU/mL
Code-Specific Risks
- Incorrectly using for asymptomatic bacteriuria
Coding Notes
- Ensure documentation of symptoms and culture results.
R31.1 - Benign microscopic hematuria
Use when hematuria is detected without infection.
Applicable To
- Microscopic hematuria
Excludes
- Gross hematuria (R31.0)
Clinical Validation Requirements
- Microscopic blood in urine without infection
Coding Notes
Document urinalysis findings clearly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Bacteriuria
R82.71Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Urine Culture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N39.0.
Impact
Clinical: Leads to unclear diagnosis., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always include CFU/mL in reports, Train staff on documentation standards
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use R82.71 for asymptomatic bacteriuria.
Impact
Incomplete documentation of culture results.
Mitigation Strategy
Implement thorough documentation protocols.
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 Urine Culture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Urine Culture
Use these documentation templates to ensure complete and accurate documentation for Urine Culture. These templates include all required elements for proper coding and billing.
UTI Diagnosis
Specialty: UrologyRequired Elements
- Patient symptoms
- Urinalysis results
- Culture findings
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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