ICD-10 Coding for Candiduria(B37.49, N39.0)
Complete ICD-10-CM coding and documentation guide for Candiduria. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Candiduria
B37.4-B37.49Primary Range
Candidiasis of other urogenital sites
This range includes codes for candidiasis affecting the urogenital tract, including candiduria.
Urinary tract infection, site not specified
Used as an ancillary code when a UTI is present alongside candiduria.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| B37.49 | Other urogenital candidiasis | Use when candiduria is confirmed as an infection by a clinician. |
|
| N39.0 | Urinary tract infection, site not specified | Use when a UTI is present but the specific site 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 candiduria
Essential facts and insights about Candiduria
Primary ICD-10-CM Codes for candiduria
Decision Criteria
clinical Criteria
- Presence of symptoms such as dysuria or urgency with positive urine culture for Candida.
documentation Criteria
- Clinician confirmation that Candida is causing an infection.
Applicable To
- Candiduria
Excludes
- B37.9 - Candidiasis, unspecified
Clinical Validation Requirements
- Urine culture showing Candida species ≥10³ CFU/mL
- Clinician documentation confirming candiduria as an infection
Code-Specific Risks
- Risk of coding without clinical confirmation of infection.
Coding Notes
- Ensure Candida is confirmed as the causative agent of infection, not just colonization.
N39.0 - Urinary tract infection, site not specified
Use when a UTI is present but the specific site is not specified.
Clinical Validation Requirements
- Symptoms of UTI such as pyuria, positive leukocyte esterase, or nitrites.
Coding Notes
Ensure documentation supports the presence of a UTI.
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 Candiduria to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code B37.49.
Impact
Clinical: Leads to inaccurate clinical data., Regulatory: May result in audits for incorrect coding., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Ensure documentation specifies the site of infection., Use B37.49 for urogenital candidiasis.
Impact
Reimbursement: Incorrect coding can lead to denied claims or reduced reimbursement., Compliance: May trigger audits if Candida is not confirmed as the causative agent., Data Quality: Impacts the accuracy of clinical data and patient records.
Mitigation Strategy
Require documentation linking Candida to symptoms or treatment.
Impact
Coding candiduria based solely on lab results without symptoms or clinician confirmation.
Mitigation Strategy
Require documentation of symptoms and clinician confirmation.
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 Candiduria, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Candiduria
Use these documentation templates to ensure complete and accurate documentation for Candiduria. These templates include all required elements for proper coding and billing.
Inpatient documentation for candiduria
Specialty: Infectious DiseaseRequired Elements
- Symptoms such as dysuria or urgency
- Urine culture results
- Clinician's assessment
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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