Capture This Cystitis Diagnosis With N30.00
Question: An established patient presents to a primary care office with a three-day history of dysuria, urinary frequency, and suprapubic pressure. The physician documents no fever, flank pain, nausea, or vomiting. Urine dipstick testing performed in the office is positive for leukocytes and nitrites. The physician diagnoses acute cystitis without hematuria and prescribes oral antibiotics. How do I code this? Codify Subscriber Answer: You can report this diagnosis with ICD-10-CM code N30.00 (Acute cystitis without hematuria). The physician documented a specific diagnosis, which this code captures, meaning you don’t need to report any of the mentioned signs or symptoms, as they are integral to the condition diagnosed. Remember, ICD-10-CM diagnosis coding in the outpatient setting is based on the provider’s final documented assessment for the encounter. The record should include the reason for the visit, pertinent symptoms, relevant negatives, any diagnostic testing performed and reviewed, the physician’s final diagnosis, and the treatment plan. Clear documentation linking the clinical findings to the assessed diagnosis is crucial to support code specificity and medical necessity. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
