ICD-10 Coding for Urinalysis(R31.1, N39.0)
Complete ICD-10-CM coding and documentation guide for Urinalysis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Urinalysis
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R31.1 | Benign essential microscopic hematuria | Use when microscopic hematuria is confirmed by laboratory findings. |
|
| N39.0 | Urinary tract infection, site not specified | Use when a UTI is diagnosed based on symptoms and urinalysis 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 urinalysis
Essential facts and insights about Urinalysis
Primary ICD-10-CM Codes for urinalysis
Decision Criteria
clinical Criteria
- Presence of ≥3 RBCs/HPF on urinalysis
Applicable To
- Microscopic hematuria
Excludes
- Gross hematuria (R31.0)
Clinical Validation Requirements
- Confirmed by ≥3 RBCs/HPF on 2+ specimens
Code-Specific Risks
- Misclassification if not confirmed by lab results
Coding Notes
- Ensure laboratory confirmation of microscopic hematuria before coding.
N39.0 - Urinary tract infection, site not specified
Use when a UTI is diagnosed based on symptoms and urinalysis results.
Applicable To
- UTI
Excludes
- Asymptomatic bacteriuria (R82.71)
Clinical Validation Requirements
- Positive leukocyte esterase and nitrites with symptoms
Coding Notes
Ensure symptoms are documented to support UTI diagnosis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Urinalysis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R31.1.
Impact
Clinical: Leads to misdiagnosis, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Always document specific lab results, Ensure linkage to clinical symptoms
Impact
Reimbursement: Potential denial due to lack of specificity, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data representation
Mitigation Strategy
Document whether hematuria is microscopic or gross and use specific codes R31.0 or R31.1.
Impact
High risk of denial if billed without proper modifiers
Mitigation Strategy
Use modifier 25 and document distinct E&M services.
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 Urinalysis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Urinalysis
Use these documentation templates to ensure complete and accurate documentation for Urinalysis. These templates include all required elements for proper coding and billing.
Urinalysis for suspected UTI
Specialty: Primary CareRequired Elements
- Patient symptoms
- Urinalysis results
- Diagnosis
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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