Ob-Gyn Coding Alert

Question: I have a dictation that states the patient was having vagina irritation, no abnormal discharge, dysuria, or urgency for two days. Upon exam, everything is normal. The physician documented that this was -consistent with- a urinary tract infection. She used the UTI as the diagnosis, and treatment was with an antibiotic. I thought I could not code a UTI unless I had a confirmed lab result. Should I report this as 623.9 (Unspecified noninflammatory disorder of vagina) for the irritation instead? At this time, I have no urine result back yet to know if it was positive.

Florida Subscriber

Answer: The words -consistent with- do not give a definitive diagnosis, which means you should not assume the patient has the condition that the results are -consistent with.- You should wait for the urine test result.
 
ICD-9 guidelines and the American Hospital Association's publication Coding Clinic speak to how you should handle diagnosis coding under these circumstances. Coding Clinic recommends that you treat these -consistent with- and -compatible with- situations as -probable,- -possible- and -likely- diagnoses.
 
According to ICD-9 guidelines, -Do not code conditions that are referred to as -rule out,- -suspected,- -probable- or -questionable.- - Instead, if a definitive diagnosis has not yet been determined, you should report diagnosis codes for the symptoms that the patient presents with.