ED Coding and Reimbursement Alert
Prove Urine Test Medical Necessity With Accurate ICD-10 Codes
Your ED bills these services frequently, so pinpoint the right codes. When patients present to your ED with possible urinary tract infections (UTIs), your provider is likely to administer a urine culture or urinalysis. To report the services accurately, you'll need to pinpoint which ICD-10 codes describe your patient's condition. Fact: Hundreds of signs, symptoms, test results, final diagnoses, and related conditions can lead to the need for urinalysis or urine culture, so your lab personnel should know how to spot diagnoses that make the grade or miss the mark to demonstrate medical necessity for one or more of the following ordered tests: Read on to learn five tips for maneuvering UTI diagnosis coding. Tip 1: Know When to Code Symptoms Physicians often order urinalysis when the patient presents with urinary symptoms that suggest a UTI, but before the patient has a known diagnosis. In those cases, you should code the signs and symptoms that the ordering physician notes as the reason for the test, such as one of the following: Sometimes patients, such as the elderly or those with neurologic disorders, may present with atypical symptoms that you'll need to code, such as acute mental status changes (R41.82, Altered mental status, unspecified) or general debility (R53.81, Other malaise). Other unusual conditions may involve suspected urosepsis resulting in symptoms such as fever of unknown origin (R50.9, Fever, unspecified) that trigger UTI testing. You might also come across a test ordered for a patient with a history of UTIs, which you can code as Z87.440 (Personal history of urinary (tract) infections). Caution: Most payers won't cover screening urinalysis or urine culture ordered with a code such as Z00.00 (Encounter for general adult medical examination without abnormal findings) or Z11.2 (Encounter for screening for other bacterial diseases). Tip 2: Specify UTI Site UTIs go by different names, depending on their location in the body. They typically occur in the kidneys (pyelonephritis), the bladder (cystitis), or the urethra (urethritis). To choose the appropriate diagnosis code, you'll need to know the specific site and which ICD-10 code describes that type of UTI. Coders should look to the following groups or individual codes to quickly narrow down the diagnosis, according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California: Johnson offers three important reminders for choosing the correct code from this list. First: You need to remember the difference between acute (sudden) and chronic (persistent). For instance, if the patient has acute cystitis, you'll report N30.0- (Acute cystitis), but if the patient's cystitis is chronic, you'll report N30.1- (Interstitial cystitis (chronic)) or N30.2- (Other chronic cystitis). Second: Based on the ICD-10 note accompanying N10, N30, and N34, you will need to use an additional code from B95-B97 to identify the infectious agent, if applicable. The infectious organism identification will depend on the results of a lab test such as a urine culture (87086, 87088) for presumptive identification or 87077 (Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate) for definitive identification. Third: Regarding the N99 codes, Johnson explains that, because they are complication codes, "they require physician documentation and confirmation of a cause-and-effect relationship between any specified procedure and the complicated condition." Tip 3: Focus UTI in Pregnancy If the patient with a UTI is pregnant, all bets are off for using any of the codes described in Tip 2. Instead, you should turn to one of the specific pregnancy UTI codes, such as the following: Tip 4: Track Urine Culture NCD For urine culture codes 87086 and 87088, CMS has issued a National Coverage Determination (NCD) that specifies conditions for coverage and non-coverage of the tests. Clinicians often order a urine culture in response to abnormal urinalysis findings indicated by ICD-10 codes such as R31.1 (Benign essential microscopic hematuria), R80.- (Proteinuria), or R82.71 (Bacteriuria). But physicians may also order urine culture as the initial test, with medical necessity indicated based on specific signs and symptoms such as those discussed in Tip 1. Tip 5: Labs Must Follow Doctor's Orders Because labs must use the physician's ordering diagnosis, ensure that your physician assigns an accurate ICD-10 code to ensure that everyone involved with the test bills the right code.
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