UTI diagnosis stating "Classic symptoms of simple UTI"

[Brenda1973]

Can this documentation be used for a UTI diagnosis in outpatient clinic. Is there any outpatient guidelines against documenting "classic symptom of? As there is an outpatient guideline against documenting "consistent with."



Assessment
- Acute uncomplicated urinary tract infection
Classic symptoms of simple UTI in female w/ hx of UTI. No red flags for pyelonephritis or other worrisome symptoms.

 

[TThivierge]

Brenda
UTI dx in ICD10 manual tells add infection code. If lab test results does not give specific bacteria go see dx B95 to B97 added with N39 dx on claim. Id use dx B96.89 if not given specific bacteria. I hope this data helps you
Lady T

 

[Brenda1973]

Brenda
UTI dx in ICD10 manual tells add infection code. If lab test results does not give specific bacteria go see dx B95 to B97 added with N39 dx on claim. Id use dx B96.89 if not given specific bacteria. I hope this data helps you
Lady T

Oh No! I always remove that code when provider adds it . Help me understand. Firstly, we are telehealth, and we do not perform lab testing.

• B96.89 - Other specified bacterial agents as the cause of diseases classified elsewhere

I always understood in all coding that "Other specified" meant the organism strain was actually known, and it is "other specified" because its known but not listed as an ICD code choice. In this case a UTI is bacterial but not specified as to which strain of bacteria, so its unspecified vs. other specified. I don't see a code for unspecified bacteria. I remove the b96.89 because the way I am interpretating its definition is for "other specified."

When I mention I don't know which strain such as E. coli, Staphylococcus, ect. as listed below:

• Escherichia coli (E. coli): The most frequent culprit in both uncomplicated and complicated UTIs. This bacteria normally resides in the intestines but can spread to the urinary tract.
  
  
• Klebsiella pneumoniae: Often found in hospital-acquired UTIs and is a common cause of complicated infections.
  
  
• Staphylococcus saprophyticus: A significant cause of UTIs in young, sexually active women.

 

[TThivierge]

Oh No! I always remove that code when provider adds it . Help me understand. Firstly, we are telehealth, and we do not perform lab testing.

• B96.89 - Other specified bacterial agents as the cause of diseases classified elsewhere

I always understood in all coding that "Other specified" meant the organism strain was actually known, and it is "other specified" because its known but not listed as an ICD code choice. In this case a UTI is bacterial but not specified as to which strain of bacteria, so its unspecified vs. other specified. I don't see a code for unspecified bacteria. I remove the b96.89 because the way I am interpretating its definition is for "other specified."

When I mention I don't know which strain such as E. coli, Staphylococcus, ect. as listed below:

• Escherichia coli (E. coli): The most frequent culprit in both uncomplicated and complicated UTIs. This bacteria normally resides in the intestines but can spread to the urinary tract.
  
  
• Klebsiella pneumoniae: Often found in hospital-acquired UTIs and is a common cause of complicated infections.
  
  
• Staphylococcus saprophyticus: A significant cause of UTIs in young, sexually active women.

Brenda
Do you have access lab results ? This will help you define and select correct bacteria dx code by looking at dx block B95 thru B97. Also if Sex transmitted bacteria look at dx blocks A52-A59.I hope helped you
Lady T

 

[Brenda1973]

Brenda
Do you have access lab results ? This will help you define and select correct bacteria dx code by looking at dx block B95 thru B97. Also if Sex transmitted bacteria look at dx blocks A52-A59.I hope helped you
Lady T

No- we are telehealth and do not perform any lab testing. Our chief medical officer is suggesting we go to symptom based diagnostic coding now for the fact that we do not test and do not have test results. Im just wondering how that will go from a reimbursement standpoint.

 

[TThivierge]

Brenda
I think the pay will be poor or none if not follow the ICD10 manual rules to add specific bacteria or add one of block B95-B97 dx code to dx. N39.0
Maybe the insurance company's algorithms do not care but usually they follow rules laid out in ICD10 manuals.
Lady T

 

[Brenda1973]

Brenda
I think the pay will be poor or none if not follow the ICD10 manual rules to add specific bacteria or add one of block B95-B97 dx code to dx. N39.0
Maybe the insurance company's algorithms do not care but usually they follow rules laid out in ICD10 manuals.
Lady T

Thank you I agree. Would you agree with me that I should not add this B96.89 dx. code because I do not know the specific bacteria. I want to educate provider not to apply this code as they have been adding it onto encounters for UTI, bacterial vaginosis and sinusitis. They aren't testing and cannot confirm its "other specified bacterial agents." Even if patient tests at home and UTI test is positive, I would not add this code unless the bacterial was identified and documented, correct?

• B96.89 - Other specified bacterial agents as the cause of diseases classified elsewhere

 

[TThivierge]

Thank you I agree. Would you agree with me that I should not add this B96.89 dx. code because I do not know the specific bacteria. I want to educate provider not to apply this code as they have been adding it onto encounters for UTI, bacterial vaginosis and sinusitis. They aren't testing and cannot confirm its "other specified bacterial agents." Even if patient tests at home and UTI test is positive, I would not add this code unless the bacterial was identified and documented, correct?

• B96.89 - Other specified bacterial agents as the cause of diseases classified elsewhere

Brenda
The ICD10 manual tells you to add bacteria code to dx N39.....this is used because it is causing a problem for the patient. It be nice to have the exact bacteria but if not you can use the B96. Next pt. session doc or provider will give new meds for exactly knowing the germ/bacteria on follow up session. Unless got lab proof of E.coli dxB96.2 or Staph A49.0 dx then use these detailed bacteria dx codes.
I hope helped you
Lady T