Wiki UTI & Hematuria clarification

[AmandaW]

Was hoping to get some clarification on a couple scenarios.

I'm with a Urology group and trying to code these notes correctly when, say, a patient comes in for a follow up on their UTI. They had it a week ago, was put on some antibiotics, done with the antibiotics and shows no UTI on this date of service, but a UTI was the reason for the visit. Would you still code N39.0 for UTI? Or change it to history? And for the UA lab, the reason is UTI N39.0, would you code it UTI or when no findings on the UA, do history?

With Hematuria....what if patient had it a couple days ago, before this visit, well, today he happens to not have any and none on the UA, for the office visit would you still do the active Hematuria code since that's why the patient is being seen? Or History of Hematuria since none on the UA today? Then there's the N02.9 idiopathic. Originally I went to intermittent, it directs me to idiopathic. I was wondering about that code possibly.

I appreciate any thoughts and guidance!!

 

[stephsaylor30@yahoo.com]

If the first patient was returning for a test of cure for their UTI I'd code it like this, assuming they no long have the UTI:

Primary dx: Z09-encounter for follow up exam after completed treatment fro conditions other than malignant neoplasm.
Secondary dx: Z87.440-personal history of UTI.

Z09 has the guideline to "use additional code to identify any applicable history of disease code."

For the second scenario, I'd code it Z87.448. I don't think hematuria should be reported if the patient no longer has it.

 

[toplati]

UTI's

It seems the reason for the first patient's visit is a diagnosis of UTI. A urine culture confirms whether the treatment was or was not effective. It will be documented whether treatment was effective. During the event that the patient returns with the same diagnosis then will it be considered recurrent or history of UTI.

The second patient has hematuria and is normally a sign or symptom. You may have to read the physician's progress notes because it would be unspecified if no other diagnosis or more details is made and a sign or symptom if the patient has another disease process of the urinary tract. However, hematuria is the reason for that encounter. Hope this info helps.

 

[Rajesh1]

Uti

If the first patient was returning for a test of cure for their UTI I'd code it like this, assuming they no long have the UTI:

Primary dx: Z09-encounter for follow up exam after completed treatment fro conditions other than malignant neoplasm.
Secondary dx: Z87.440-personal history of UTI.

Z09 has the guideline to "use additional code to identify any applicable history of disease code."

For the second scenario, I'd code it Z87.448. I don't think hematuria should be reported if the patient no longer has it.

Great effort !!!!!