ICD-10 Coding for History of Urinary Tract Infection(Z87.440)
Complete ICD-10-CM coding and documentation guide for History of 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 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.
Key Information: ICD-10 code for history of urinary tract infection
Essential facts and insights about History of Urinary Tract Infection
Primary ICD-10-CM Code for history of urinary tract infection
Decision Criteria
clinical Criteria
- Patient has a documented history of UTIs but is currently asymptomatic.
coding Criteria
- Do not use if the patient has an active UTI.
Applicable To
- History of recurrent urinary tract infections
Excludes
- Current urinary tract infection (N39.0)
Clinical Validation Requirements
- Documentation of past UTIs without current symptoms
- Negative current urinalysis or urine culture
- History of treatment for UTIs
Code-Specific Risks
- Incorrectly using for active infections
Coding Notes
- Ensure documentation clearly states 'history of UTIs' and that the patient is asymptomatic.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of 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: Misleading clinical picture of patient's health., Regulatory: Potential non-compliance with coding standards., Financial: Risk of claim denials due to incorrect coding.
Mitigation Strategy
Always include current symptom status in documentation, Review past medical history thoroughly
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Use N39.0 for active infections and Z87.440 for historical documentation.
Impact
Using Z87.440 for active infections can lead to audit flags.
Mitigation Strategy
Ensure clear documentation of historical vs. active status.
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 Urinary Tract Infection, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Urinary Tract Infection
Use these documentation templates to ensure complete and accurate documentation for History of Urinary Tract Infection. These templates include all required elements for proper coding and billing.
Primary Care Visit for UTI History
Specialty: Family MedicineRequired Elements
- Number of past UTIs
- Last treatment date
- Current symptom status
- Recent urinalysis results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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