ICD-10 Coding for Urethritis(N34.1, N34.2, A56.0, A54.0)
Complete ICD-10-CM coding and documentation guide for Urethritis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Urethritis
N34Primary Range
Urethritis and urethral syndrome
This range includes codes for different types of urethritis, including nonspecific and other specified types.
Sexually transmitted infections with urethritis
This range includes codes for urethritis caused by sexually transmitted infections such as gonorrhea and chlamydia.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N34.1 | Nonspecific urethritis | Use when urethritis is confirmed but not due to gonococcal or chlamydial infection. |
|
| N34.2 | Other urethritis | Use when urethritis is due to a specific non-infectious cause. |
|
| A56.0 | Chlamydial urethritis | Use when urethritis is confirmed to be due to Chlamydia trachomatis. |
|
| A54.0 | Gonococcal urethritis | Use when urethritis is confirmed to be due to Neisseria gonorrhoeae. |
|
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 nonspecific urethritis
Essential facts and insights about Urethritis
Primary ICD-10-CM Codes for urethritis
Decision Criteria
clinical Criteria
- Negative STI testing and presence of urethral symptoms.
Applicable To
- Urethritis not due to gonococcal or chlamydial infection
Clinical Validation Requirements
- Negative NAAT for GC/CT
- ≥10 WBC/high-power field in first-void urine
Code-Specific Risks
- Misclassification if STI is present but not documented.
Coding Notes
- Ensure STI testing is documented to support the use of this code.
N34.2 - Other urethritis
Use when urethritis is due to a specific non-infectious cause.
Applicable To
- Urethritis due to trauma or chemical irritation
Clinical Validation Requirements
- Documented cause such as catheterization or chemical exposure
Coding Notes
Specify the cause of urethritis in the documentation.
A56.0 - Chlamydial urethritis
Use when urethritis is confirmed to be due to Chlamydia trachomatis.
Applicable To
- Urethritis due to Chlamydia trachomatis
Clinical Validation Requirements
- Positive NAAT for Chlamydia trachomatis
Coding Notes
Ensure laboratory confirmation of Chlamydia infection.
A54.0 - Gonococcal urethritis
Use when urethritis is confirmed to be due to Neisseria gonorrhoeae.
Applicable To
- Urethritis due to Neisseria gonorrhoeae
Clinical Validation Requirements
- Gram stain with intracellular diplococci or positive GC NAAT
Coding Notes
Ensure laboratory confirmation of gonococcal infection.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Complication of urinary catheter
T83.511ADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Urethritis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N34.1.
Impact
Clinical: Inaccurate diagnosis leading to inappropriate treatment., Regulatory: Potential audit issues due to incomplete documentation., Financial: Denial of claims due to lack of specificity.
Mitigation Strategy
Always document the specific cause of urethritis., Review patient history for potential causes.
Impact
Reimbursement: Incorrect reimbursement due to misclassification., Compliance: Non-compliance with coding guidelines., Data Quality: Poor data quality affecting epidemiological studies.
Mitigation Strategy
Code A56.0 or A54.0 first if STI is confirmed.
Impact
Lack of documented negative STI testing when using N34.1.
Mitigation Strategy
Ensure all STI tests are documented in the patient record.
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 Urethritis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Urethritis
Use these documentation templates to ensure complete and accurate documentation for Urethritis. These templates include all required elements for proper coding and billing.
Urethritis in a primary care setting
Specialty: Primary CareRequired Elements
- Patient symptoms
- Sexual history
- Laboratory results
- Final diagnosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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