Wiki Help with hematuria

[danachock]

Hi, I am curious on how others code "red blood cells" on a urinalysis for review for cytology.

Let me just randomly throw out an example off the top of my head for my question.

Gross: Received 40 mls of tinged yellow urine in a sterile container labeled xxxxpatient; xxxxdate; for assessment.

Microscopic:
Red blood cells
Bacteria (probably or possibly a vaginal contaminant)

There is a disclaimer that "microscopic was performed at the bottom of the pathology report by the pathologist" ~ but how would you code this scenario?
I'm curious on my colleagues observations and coding habits and hoping for some assistance on why a diagnosis was selected please and the rationale.
I appreciate anyone that participates in my request in advance. I completely appreciate anyone's advice please.
Thank you for listening,
Dana

 

[LaurieEaston]

Hi Dana,
You have a way of making me question the status-quo of the way I have been taught/directed to code certain (often what appear to be simple) common coding scenarios. I've been thinking about this since you posted and have been hesitant to answer for fear of being "wrong", but I've decided to bite. Sometimes it seems to be the best way to learn... taking the risk.

This is not the wording used on the final cytology reports seen at the practice I work for, but with that being said I would be sure to check documentation to make sure that no other symptoms were documented. If that is the case then I think R31.21 - Asymptomatic microscopic hematuria would be most appropriate.
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But I am now a bit unsure of my conclusion. If I go to the Alpha Index under Hematuria>microscopic I see that there is another entry microscopic>benign essential>R31.1 which might be a better option?

It is interesting to note that the APF Pathology Service Coding Handbook does not reference R31.21. Their ICD-10 "Crib" sheet references microscopic hematuria as R31.29 - Other microscopic hematuria. In our practice, we have been using R31.29 - Other microscopic hematuria for cases similar to this one (but not worded exactly).

I also looked at the Coding Clinic - copied and pasted below:
AHA Coding Clinic (Microscopic Hematuria (2016 Vol3, No 4).
Microscopic Hematuria
Code R31.2, has been expanded to uniquely identify asymptomatic microscopic hematuria (R31.21) and other microscopic hematuria (R31.29). Prior to this change, microscopic hematuria was classified to code R31.2, Other microscopic hematuria. The American Urological Association requested a unique code for asymptomatic microscopic hematuria.
Hematuria is the presence of red blood cells in the urine. Gross hematuria is the term used to describe blood in the urine that can be seen with the naked eye, while microscopic hematuria is detected by the dipstick method or microscopic examination of the urinary sediment. In current urologic practice, asymptomatic microscopic hematuria (AMH) is a common condition for urology referral and evaluation. There are many causes of AMH including urinary tract infection, urethral calculus, benign prostatic hyperplasia and bladder tumor.

I will be watching this thread and am interested in how you and others might break this down. I am also very much looking forward to your presentation on November 10th on cytology coding. I know it will make me a better coder.

Laurie Easton, CPC, CPB