ICD-10 Coding for Frequent Urinary Tract Infection(N39.0, Z87.440)
Complete ICD-10-CM coding and documentation guide for Frequent Urinary Tract Infection. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Frequent Urinary Tract Infection
N30-N39Primary Range
Diseases of the urinary system
This range includes codes for various urinary tract infections, including cystitis and other urinary tract disorders.
Personal history of diseases of the urinary system
This range is used for documenting a personal history of urinary tract infections without current active infection.
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 UTI is active and the site is not specified. |
|
| Z87.440 | Personal history of urinary (tract) infections | Use for documenting a history of UTIs when no active infection is present. |
|
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 frequent urinary tract infections
Essential facts and insights about Frequent Urinary Tract Infection
Primary ICD-10-CM Codes for frequent urinary tract infection
Decision Criteria
clinical Criteria
- Presence of UTI symptoms and positive urine culture
documentation Criteria
- Lack of specified site in documentation
Clinical Validation Requirements
- Symptoms of dysuria, frequency, and urgency
- Positive urine culture
Code-Specific Risks
- Risk of under-coding if site is specified but not documented
Coding Notes
- Ensure documentation specifies if the infection is acute or chronic and any identified organism.
Z87.440 - Personal history of urinary (tract) infections
Use for documenting a history of UTIs when no active infection is present.
Applicable To
- History of recurrent UTIs without current infection
Excludes
- Current UTI (N39.0)
Clinical Validation Requirements
- Documented history of recurrent UTIs
- No current symptoms or active infection
Coding Notes
Ensure documentation clearly states the historical nature of the condition.
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 Frequent Urinary Tract 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 treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Review documentation for specificity, Educate providers on importance of detailed notes
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Use N39.0 for active infections and Z87.440 for historical documentation only.
Impact
Using Z87.440 for active infections.
Mitigation Strategy
Educate coding staff on proper use of history codes.
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 Frequent Urinary Tract Infection, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Frequent Urinary Tract Infection
Use these documentation templates to ensure complete and accurate documentation for Frequent Urinary Tract Infection. These templates include all required elements for proper coding and billing.
Recurrent UTI in primary care
Specialty: Primary CareRequired Elements
- Chief complaint
- History of present illness
- Lab results
- Imaging findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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