Using additional the ICD-9 book


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In the ICD-9, if the directions state "Use additional code to identify organism, such as...", is this additional code mandatory? An example - UTI 599.0 states this. I have never used an additional code with this diagnosis.
I have not used an additional code either, mostly because there is not one stated in dictation or documentation in regards to what the organism is. If I had such info I would include it. Most lab reports that we get at a later date might specify but the charge has been billed by then.
additional code

Most times an infection of any kind will lead you down this path. If you know the organism causing the infection, then you can and should code that. However, especially in most Dr. offices, the patient is there due to the symptoms of the infection and the organism is not yet known so the Dr. doesn't document this. In the outpatient hospital, when the patient presents to the laboratory for a urinalysis or culture, again, the organism is not known and we can't code from the laboratory reports, that has to be indicated by the physician. So, in saying all this :D you are correct in not using the organism code in the 599.0 unless the Dr. knows what it is and indicates the organism in his dictation/written documentation. Hope this helps explain a little.