Urology Coding Alert

Question: When is it appropriate to code the signs and symptoms when a patient comes in for a suspected urinary tract infection (UTI)?

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Answer: Your urologist may need to order or perform a 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 your urologist 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)

If your practitioner has ordered a test for a patient with a history of UTIs, you should code this as Z87.440 (Personal history of urinary (tract) infections).

Don’t miss: Most payers won’t cover screening urinalysis or urine culture ordered with a code such as Z11.2 (Encounter for screening for other bacterial diseases).