ICD-10 Coding for History of Recurrent Urinary Tract Infection(Z87.440, N39.0)
Complete ICD-10-CM coding and documentation guide for History of Recurrent 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 History of Recurrent Urinary Tract Infection
Z87.4Primary Range
Personal history of diseases of the genitourinary system
This range includes codes for personal history of urinary tract infections, specifically Z87.440 for history of recurrent UTIs.
Urinary tract infection, site not specified
This range is used for active urinary tract infections, which may be confused with historical codes if not properly documented.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z87.440 | Personal history of urinary (tract) infections | Use when the patient has a documented history of recurrent UTIs but no current active infection. |
|
| N39.0 | Urinary tract infection, site not specified | Use when the patient presents with active symptoms of a UTI and positive lab results. |
|
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 history of recurrent urinary tract infection
Essential facts and insights about History of Recurrent Urinary Tract Infection
Primary ICD-10-CM Codes for history of recurrent urinary tract infection
Decision Criteria
clinical Criteria
- Patient has a history of recurrent UTIs with no current symptoms.
documentation Criteria
- History of UTIs is documented with dates and treatments.
Applicable To
- History of recurrent urinary tract infections
Excludes
- Current urinary tract infection (N39.0)
Clinical Validation Requirements
- Documented history of ≥2 UTIs in past 6 months or ≥3 in past year
- No current symptoms of UTI
- Negative urinalysis or culture
Code-Specific Risks
- Incorrectly coding active infections as historical
- Lack of documented history leading to audit risks
Coding Notes
- Ensure documentation clearly states the absence of current symptoms and includes a quantified history of past infections.
N39.0 - Urinary tract infection, site not specified
Use when the patient presents with active symptoms of a UTI and positive lab results.
Applicable To
- Active urinary tract infection
Excludes
- History of urinary tract infections (Z87.440)
Clinical Validation Requirements
- Positive urinalysis or culture
- Current symptoms such as dysuria or frequency
Coding Notes
Ensure active symptoms and positive lab results are documented.
Differential 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 History of Recurrent Urinary Tract Infection to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z87.440.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Potential for audit issues due to incorrect coding., Financial: Claims may be denied or reimbursed incorrectly.
Mitigation Strategy
Ensure thorough documentation of current symptom status, Review patient history before coding
Impact
Reimbursement: Incorrect coding can lead to denied claims or incorrect payments., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Ensure documentation specifies no current symptoms and a history of UTIs.
Impact
Using Z87.440 for active infections can trigger audits.
Mitigation Strategy
Ensure documentation clearly differentiates between historical and active infections.
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 History of Recurrent Urinary Tract Infection, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Recurrent Urinary Tract Infection
Use these documentation templates to ensure complete and accurate documentation for History of Recurrent Urinary Tract Infection. These templates include all required elements for proper coding and billing.
Routine follow-up for history of recurrent UTIs
Specialty: UrologyRequired Elements
- History of UTIs with dates
- Current symptom status
- Urinalysis results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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