Ob-Gyn Coding Alert

Reader Questions:

Look to Code First Note in This Type 2 Diabetes/UTI Encounter

Question: What is the correct way to code for type 2 diabetes and a urinary tract infection (UTI)? Should I use E11.69 or E11.29?

Pennsylvania Subscriber

Answer: The correct way to code for this will be completely dependent on the way your provider has documented the patient’s condition. If the patient’s diabetes is the cause of the UTI, which is true for patients whose diabetes is long-term and poorly controlled and who have developed complications such as renal papillary necrosis, cystopathy, or nephropathy as a consequence, then E11.69 (Type 2 diabetes mellitus with other specified complication) or E11.29 (Type 2 diabetes mellitus with other diabetic kidney complication) may be appropriate codes to use.

Should you go with E11.69, however, you should be aware of the “Use additional code to identify complication” note that goes with it. This means you would code the UTI as well using a code such as N39.0 (Urinary tract infection, site not specified), N10 (Acute pyelonephritis), N30.- (Cystitis), N34.- (Urethritis and urethral syndrome), or O23.4- (Unspecified infection of urinary tract in pregnancy) as appropriate. But note that the code O23.4 would always be primary since the patient is pregnant.

However, should the provider document that the two conditions are not related, you’ll code the diabetes with E11.9 (Type 2 diabetes mellitus without complications) and an appropriate code for the UTI, assuming that the ob-gyn addressed both conditions that day.

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