Pathology/Lab Coding Alert

Target symptoms, site, condition, and more.

Urinalysis and urine culture are commonly-ordered lab tests to help ferret out urinary tract infections (UTIs), so you can't afford to lose pay based on bogus diagnosis coding.

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:

• 81000 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, ph, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy)
• 81001 (... automated, with microscopy)
• 81002 (... non-automated, without microscopy)
• 81003 (... automated, without microscopy)
• 81005 (Urinalysis; qualitative or semiquantitative, except immunoassays)
• 81007 (Urinalysis; bacteriuria screen, except by culture or dipstick)
• 81015 (Urinalysis; microscopic only)
• 87086 (Culture, bacterial; quantitative colony count, urine)
• 87088 (... with isolation and presumptive identification of each isolate, urine).

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:

• R30.- (Pain associated with micturition)
• R31.- (Hematuria)
• R33.- (Retention of urine)
• R34.- (Anuria and oliguria)
• R35.- (Polyuria)
• R39.1- (Other difficulties with micturition).

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:

• N10 (Acute pyelonephritis)
• N30.- (Cystitis)
• N34.- (Urethritis and urethral syndrome)
• N39.0 (Urinary tract infection, site not specified)
• N99.521 (Infection of incontinent external stoma of urinary tract)
• N99.531 (Infection of continent stoma of urinary tract).

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:

• O23.4- (Unspecified infection of urinary tract in pregnancy)
• O03.38 (Urinary tract infection following incomplete spontaneous abortion)
• O03.88 (... following complete or unspecified spontaneous abortion)
• O04.88 (... following (induced) termination of pregnancy)
• O08.83 (... following an ectopic and molar pregnancy)
• O86.2- (... following delivery).

Additionally: If the patient is a neonate, you should also avoid the codes listed in Tip 2. Instead, you should immediately go to P39.3 (Neonatal urinary tract infection), as the ICD-10-CM index suggests. A note accompanying P39.3 instructs you to use an additional code to identify the organism or specific infection.

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 codessuch 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 asthose discussed in Tip 1.

Follow up: Medicare and some other payers may not cover follow-up urine culture for an uncomplicated infection. But if there are ongoing symptoms, or complicating or co-existing structural or functional abnormalities, or history of chronic UTI, appropriate diagnosis documentation can demonstrate medical necessity in these circumstances.

Although physicians may order urine culture for asymptomatic bacteriuria as part of a prenatal evaluation, CMS considers the service a screening test. That means you shouldn't expect Medicare or many other payers to cover the test when reported with Z36.89 (Encounter for other specified antenatal screening) as the ordering diagnosis.

Tip 5: Follow Doctor's Orders

Because labs must use the physician's ordering diagnosis, you'll typically assign the ICD-10 code yourself only when you receive a narrative diagnosis.

Bottom line: To help you find the right ICD-10 code, you can use a search engine such as the one available at https://www.aapc.com/codes/. But never fail to "go with what the doctor has written," advises Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Michigan.