Wiki Urinary urgency

[terribrown]

In an inpatient setting, the patient is documented with sepsis due to UTI (E. coli is the stated causal organism), urinary urgency x 3 days and BPH (among other DX not essential to my question.)

The "with" guideline at I.A.15, allows us to assume a link between certain conditions and this would apply to BPH with LUTS because of the urinary urgency. Instructional notes at N40.1 requires an additional code for the associated symptom(s). However, because the symptom of urinary urgency is noted for the past three days, and because the provider does not state if the urgency is related to BPH or the UTI, is it still appropriate to link urinary urgency to BPH to code with LUTS for N40.1 and R39.15...or since not clear, would we code the N40.0 for the BPH without LUTS ...and because the urgency could be a s/s of the sepsis due to UTI, we would not code the R39.15 per Official Guideline I.B.5?

I know it would be best to query the provider for clarification, but this is impossible in a retrospective review.

 

[malcorn]

In an inpatient setting, the patient is documented with sepsis due to UTI (E. coli is the stated causal organism), urinary urgency x 3 days and BPH (among other DX not essential to my question.)

The "with" guideline at I.A.15, allows us to assume a link between certain conditions and this would apply to BPH with LUTS because of the urinary urgency. Instructional notes at N40.1 requires an additional code for the associated symptom(s). However, because the symptom of urinary urgency is noted for the past three days, and because the provider does not state if the urgency is related to BPH or the UTI, is it still appropriate to link urinary urgency to BPH to code with LUTS for N40.1 and R39.15...or since not clear, would we code the N40.0 for the BPH without LUTS ...and because the urgency could be a s/s of the sepsis due to UTI, we would not code the R39.15 per Official Guideline I.B.5?

I know it would be best to query the provider for clarification, but this is impossible in a retrospective review.

I would code N40.1 and R39.15 because of the subterm "with" and the instructional note under BPH. ICD-10-CM conventions and instructions take precedence over guidelines. Since the provider did not state that the urinary urgency is not related to the BPH, you can code the sepsis and E. coli UTI, BPH with LUTS, and urinary urgency.

Hope that helped!