ICD-10 Coding for Bacteria in Urine(N39.0, R82.71)
Complete ICD-10-CM coding and documentation guide for Bacteria in Urine. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bacteria in Urine
N30-N39Primary Range
Diseases of the urinary system
This range includes codes for urinary tract infections and related conditions.
Other bacterial agents as the cause of diseases classified elsewhere
This range is used to specify the bacterial cause of a urinary tract infection.
Other abnormal findings in urine
This range includes codes for findings such as asymptomatic bacteriuria.
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 UTI is diagnosed without a specified site. |
|
| R82.71 | Bacteriuria | Use when bacteria are present in urine without symptoms. |
|
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 bacteria in urine
Essential facts and insights about Bacteria in Urine
Primary ICD-10-CM Codes for bacteria in urine
Decision Criteria
clinical Criteria
- Presence of UTI symptoms and positive urine culture
Clinical Validation Requirements
- Presence of symptoms such as dysuria, urgency
- Positive urine culture with ≥10^5 CFU/mL
Code-Specific Risks
- Incorrect use without documented symptoms
Coding Notes
- Ensure symptoms are documented to support UTI diagnosis.
R82.71 - Bacteriuria
Use when bacteria are present in urine without symptoms.
Applicable To
- Asymptomatic bacteriuria
Excludes
- Symptomatic UTI (N39.0)
Clinical Validation Requirements
- Positive urine culture without symptoms
Coding Notes
Do not use for symptomatic cases.
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
B96.2Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bacteria in Urine to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N39.0.
Impact
Clinical: Misrepresents patient condition, Regulatory: Non-compliance with coding standards, Financial: Potential claim rejections
Mitigation Strategy
Verify symptom documentation, Use R82.71 for asymptomatic cases
Impact
Reimbursement: May lead to claim denials, Compliance: Violates coding guidelines, Data Quality: Inaccurate clinical data
Mitigation Strategy
Ensure symptoms are documented before coding as UTI.
Impact
Coding UTI without documented symptoms can trigger audits.
Mitigation Strategy
Ensure documentation of symptoms and lab results.
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 Bacteria in Urine, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bacteria in Urine
Use these documentation templates to ensure complete and accurate documentation for Bacteria in Urine. These templates include all required elements for proper coding and billing.
Symptomatic UTI
Specialty: Primary CareRequired Elements
- Chief complaint
- Urinalysis results
- Culture results
- Diagnosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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