UTI vs symptoms

CPCA2016

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Hi there,
My question is when coding for Urgent Care Facilities, many patients present with symptoms of UTIs. The culture is done, and sent, therefore no B code is available to code as the cause of the infection is unknown, however all the providers diagnose UTI. I have done a lot of research on this and currently have been coding only the symptoms because technically it is not confirmed until the culture returns, in about 2 days time. Also, N39.0 states to use additional code to identify the infectious agent. However, I have read on this forum some say code N39.0 without the B code. Which of course is against the coding guidelines. Also, I have seen that some of our billers have coded N39.0 with out the B code and I'm unsure if it was paid or not. What on earth is the correct answer to this?

I am a CPC-A as of December 2015 and I am working for a billing company. I am the only coder employed there and the rest of the employees are billers that do coding as well. This causes me to raise an eyebrow but it seems they know what gets paid. However, I ask, why did I need to take the entire coding coursed and pass a rigorous exam to code when billers are doing it with out any of that experience?

I am new to this environment and I do realize I have a lot to learn. I am grateful to be employed in an environment where I can learn but I have a ton of questions. Any insight to learning coding vs coding in the real world will be greatly appreciated! :)
 
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You are correct that you should only be coding for the symptoms until a definitive diagnosis is made. However, N39.0 is a UTI diagnosis, not a symptom code. The symptom codes fall in the R00-R94 range. For example, R35.0 Frequency of micturition or R39.15 Urgency of urination. Those codes have a "code first" guideline, however that's only applicable if there is another condition that is contributing to the symptom. Once a confirmed diagnosis is made, then you code for that diagnosis instead of the symptoms, as long as the symptom can be attributed to the diagnosis.
 

CPCA2016

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That's what I've been coding-the symptoms for it not the UTI. I just wanted to make sure that was correct because I've seen other discussions saying they were coding the UTI. Thank you for the clarification and glad to know I am coding it correctly.
 

mitchellde

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Hi there,
My question is when coding for Urgent Care Facilities, many patients present with symptoms of UTIs. The culture is done, and sent, therefore no B code is available to code as the cause of the infection is unknown, however all the providers diagnose UTI. I have done a lot of research on this and currently have been coding only the symptoms because technically it is not confirmed until the culture returns, in about 2 days time. Also, N39.0 states to use additional code to identify the infectious agent. However, I have read on this forum some say code N39.0 without the B code. Which of course is against the coding guidelines. Also, I have seen that some of our billers have coded N39.0 with out the B code and I'm unsure if it was paid or not. What on earth is the correct answer to this?

I am a CPC-A as of December 2015 and I am working for a billing company. I am the only coder employed there and the rest of the employees are billers that do coding as well. This causes me to raise an eyebrow but it seems they know what gets paid. However, I ask, why did I need to take the entire coding coursed and pass a rigorous exam to code when billers are doing it with out any of that experience?

I am new to this environment and I do realize I have a lot to learn. I am grateful to be employed in an environment where I can learn but I have a ton of questions. Any insight to learning coding vs coding in the real world will be greatly appreciated! :)
Providers are allowed to diagnose the presence of an infection or infective condition based only on the presentation of the patient. There is no requirement that a culture even be submitted. Therefore if the provider documents the diagnosis of a UTI based on the symptoms then that is totally fine and the coder will code this as a UTI without a culture report. coding the N39.0 without a B code is not against coding guidelines. You just will not have one to assign. As long as the code is based on the provider rendering the diagnosis and not the coder deciding to use the code based on documented symptoms.
 
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I can't find any documentation that says it's permitted to use the diagnosis for UTI, so personally I'll stick with reporting the signs and symptoms. I'd rather err on the side of caution and follow the guidelines I actually have in hand. To each their own.
 

mitchellde

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If the provider documents a UTI then the coder is to code the documented diagnosis. Coding clinics have covered this in numerous issues. In addition the 2017 coding guidelines cover this. The provider does not need clinical confirmation for an infection. I don't see why this is a problem for anyone.
 
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If the provider documents a UTI then the coder is to code the documented diagnosis. Coding clinics have covered this in numerous issues. In addition the 2017 coding guidelines cover this. The provider does not need clinical confirmation for an infection. I don't see why this is a problem for anyone.
I'm not sure why this has turned into something you feel the need to continue on about. It's not a problem for anybody except you as far as I can tell. As I said, to each their own. You code your way and I'll code my way.

For the time being, do you think you could take it down a notch and stop trying to force me and/or anyone else to do something I am/we are not comfortable with? It'd be very much appreciated. If you want to be "right" about it, that's fine too. I'll be wrong. I'd just prefer not to have it shoved down my throat. It's very discouraging.
 

mitchellde

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I am not trying to shove anything down. In coding there is a correct and compliant way to code and there is the other way. I prefer to teach and instruct the compliant and correct way. This is not a "to each his own" kind of business. When I see incorrect or misleading issues I will address it. You can take this and learn something or you can chose to not learn anything. However the patient is counting on you to be absolutely correct in the assignment of their diagnosis code.
So whatever else you take away from this, know that a coder may not pick and chose the diagnosis code. The guidelines do have instructions regarding assignment of definitive diagnosis vs the symptoms, and everything hinges on the documentation.
 

TheStephCode

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If the provider documents a UTI then the coder is to code the documented diagnosis.
I think it is outside the scope of coding and entering into the world of a PhD in medicine to challenge a doctor on his diagnosis. We should protect our providers in the scope of coding and documentation compliancy but refrain from crossing into diagnosing/undiagnosing a patient.

I agree with Debra. If an MD specifically diagnoses a condition, code it. "Likely", "probable" and similar wording should give us pause, but if the diagnosis is clearly definitive a coder should not challenge the MDs process of diagnosis.
 
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mitchellde

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I thought you might like to see this, from 2017 guidelines:
19. Code assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.
 
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