ICD-10 Coding for Recurrent Infection(N39.0, Z87.440, A41.9)
Complete ICD-10-CM coding and documentation guide for Recurrent Infection. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Recurrent Infection
N39.0Primary Range
Urinary tract infection, site not specified
Primary code for active recurrent urinary tract infections.
Personal history of urinary (tract) infections
Used for historical documentation of recurrent UTIs when no active infection is present.
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 | For active recurrent UTIs with current infection. |
|
| Z87.440 | Personal history of urinary (tract) infections | For historical documentation of recurrent UTIs when no active infection is present. |
|
| A41.9 | Sepsis, unspecified organism | When sepsis is due to a recurrent infection. |
|
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 recurrent UTI
Essential facts and insights about Recurrent Infection
Primary ICD-10-CM Codes for recurrent infection
Decision Criteria
clinical Criteria
- Presence of ≥2 positive urine cultures within 6 months.
Applicable To
- Recurrent urinary tract infection
Excludes
- Chronic pyelonephritis (N11.1)
Clinical Validation Requirements
- Urine culture ≥10^5 CFU/mL
- Pyuria
Code-Specific Risks
- Incorrectly coding as Z87.440 when infection is active.
Coding Notes
- Ensure documentation specifies 'recurrent' and includes culture results.
Z87.440 - Personal history of urinary (tract) infections
For historical documentation of recurrent UTIs when no active infection is present.
Applicable To
- History of recurrent urinary tract infections
Excludes
- Current urinary tract infection (N39.0)
Clinical Validation Requirements
- Documented history of UTIs without current symptoms.
Coding Notes
Ensure no current infection is present.
A41.9 - Sepsis, unspecified organism
When sepsis is due to a recurrent infection.
Applicable To
- Sepsis due to recurrent infection
Excludes
- Localized infection without sepsis
Clinical Validation Requirements
- SIRS criteria
- Positive blood culture
Coding Notes
Ensure sepsis is documented as primary if causal.
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.
Chronic tubulo-interstitial nephritis, unspecified
N11.9Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Recurrent 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: Misrepresents current clinical status., Regulatory: Non-compliance with coding standards., Financial: Potential for incorrect reimbursement.
Mitigation Strategy
Verify current infection status before coding., Educate staff on code differences.
Impact
Reimbursement: Incorrect DRG assignment., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Code sepsis first if it is the reason for admission.
Impact
Incorrect sequencing of sepsis and localized infections.
Mitigation Strategy
Regular training on ICD-10 guidelines.
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 Recurrent Infection, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Recurrent Infection
Use these documentation templates to ensure complete and accurate documentation for Recurrent Infection. These templates include all required elements for proper coding and billing.
Recurrent UTI in a urology clinic
Specialty: UrologyRequired Elements
- History of UTIs
- Current symptoms
- Lab results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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