ICD-10 UTI Coding System

What is UTI Coding?

ICD 10 Code for urinary tract infection varies depending on the specific location of the infection within the urinary tract. The most commonly used codes to report UTI are N39.0, N39.41, N39.42, N30.00, and N30.01.

UTI stands for Urinary Tract Infection. UTIs are infections caused by bacteria that enter the urethra from the skin or the rectum. The infection can be in any part of the urinary tract, kidneys, ureters, bladder, or urethra ( the bladder and urethra are most commonly infected).

UTI is a broad term that encompasses many conditions, including asymptomatic bacteriuria (ASB), acute and recurrent cystitis, catheter-associated bacteriuria and cystitis, pyelonephritis, and prostatitis. Acute cystitis is the most common manifestation of urinary tract infection. The prevalence of UTI is higher in women as compared to men.

This article will tell you about the proper use of the ICD-10-CM codes for UTI and its associated conditions caused by bacteria and medical billing and coding general guidelines regarding the genitourinary system.

ICD-10 Coding System for Urinary Tract Infection:

World Health Organization (WHO) introduces the ICD-10 coding system for the diagnosis, treatment, and services (including billing, coding, and insurance) of diseases in a healthcare system. The coding of diseases makes it easier for healthcare providers to manage the documentation of the cases presented.

Section N00-N99 from the ICD-10-CM Manual book is made to represent all genitourinary problems and conditions, including UTIs.

This chapter classifies diseases and disorders of the reproductive and urinary systems, known as the genitourinary system. The urinary system contains a pair of kidneys, a pair of ureters, the bladder, two sphincter muscles, and the urethra.

The reproductive system is a series of organs found around the pelvic region, primarily outside the body in males and primarily inside the body in females and the male and female breasts. Although the organs and structures differ between the male and female reproductive systems, their collective purpose is sexual reproduction.

Coding of urinary tract infections (UTIs) is a tricky job. UTI coding is site-dependent, and it is necessary to know which area is involved in the kidney, bladder, or urethra. Use only the Unspecified code (N39.0) if the location is not specified.

Below are the ICD-10-CM codes that are effective by WHO:

N39.0- Unspecified Urinary tract infection, site not specified.

If infection-causing bacteria is also mentioned in medical reports, use an additional code from B95-B97 in the ICD-10 manual to identify infectious agents.

N10- Acute pyelonephritis

• Acute pyelitis
• Hemoglobin nephrosis
• Acute infectious interstitial nephritis

N30- Cystitis (Cystitis is an infection of the bladder. The bladder becomes inflamed, and urination causes a burning sensation. E.coli is the leading causative agent of cystitis).

Add-on codes or secondary diagnosis codes for N39.0, N10, and N30:

B95.0- Streptococcus, group A, as the cause of diseases classified elsewhere

B95.1- Streptococcus, group B, as the cause of diseases classified elsewhere

B95.2- Enterococcus as the cause of diseases classified elsewhere

B95.3- Streptococcus pneumonia, as the cause of diseases classified elsewhere

B95.4- Other streptococci

B95.5- Unspecified streptococci

B95.7- Other staphylococci

B95.8- Unspecified staphylococci

N30.1- Chronic (interstitial) cystitis

N30.2- Other Chronic Cystitis

N30.3- Trigonitis (the infection of the trigone- neck of the urinary bladder- is called Trigonitis. It is a metaplastic process due to infection). It is also called Urethrotrigonitis.

N30.4- Irradiation cystitis (radiation therapy makes blood vessels in the bladder thin and fragile, causing inflammation of the lining of the bladder).

N30.8- Other Cystitis (this code also cites an abscess of the bladder)

N30.9- Unspecified cystitis

N11- Chronic tubulointerstitial nephritis (chronic pyelitis, chronic pyelonephritis, or chronic infectious interstitial nephritis). It is a default code and can’t be used directly.

N11.0- Nonobstructive reflux-associated chronic pyelonephritis

N11.1- Chronic obstructive pyelonephritis

N11.8- Chronic tubulointerstitial nephritis, otherwise specified

N11.9- Chronic tubulointerstitial nephritis, unspecified

• Chronic pyelitis NOS
• Chronic pyelonephritis NOS

N12- Non-specified tubule interstitial nephritis ( pyelonephritis, pyelitis, or interstitial nephritis).

N32- Other disorders of the bladder

N32.0- Bladder-neck obstruction (studies show that obstruction in the bladder results in lesser elimination of bacteria through the urethra, causing urinary tract infections). It is also termed acquired bladder-neck stenosis.

N32.1- Vesicointestinal fistula (the opening formed between the bladder and the adjacent organs-mostly rectum (vesicorectal fistula)-causing an increased risk for urinary tract infections).

N32.2- Vesical fistula, not elsewhere classified

N32.3- Diverticulum of the bladder (urinary tract infections are the complications of diverticulitis of the bladder (outpouching of the bladder) as the urine stasis in the bladder can increase the risk of developing UTIs).

N32.8- Other specified bladder disorders (calcified, contracted, and overactive bladder).

N32.9- Unspecified bladder disorders

N33- Bladder disorders in diseases classified elsewhere

N33.0- Tuberculous cystitis (Mycobacterium tuberculosis infecting the kidneys and causing bladder lesions).

N33.8- Bladder disorders in other diseases classified elsewhere

N34- Urethritis (As evident from its name, urethritis is an infection of the urethra. It is more common in females because of their anatomy (shorter urethra near the rectum). Urethral discharge, inflammation, and burning of the urethra are common symptoms of urethritis).

N34.0- Urethral abscess ( urinary tract infections, if not treated, can cause abscess formation). It includes urethral abscess, periurethral abscess, and abscess of Cowper and Littré glands.

N34.1- Nonspecific urethritis (it includes nonvenereal and nongonococcal urethritis).

N34.2- Other urethritis (includes meatitis (inflammation at the opening of the penis), postmenopausal urethritis, and ulcer of the urethra).

N34.3- Unspecified urethral syndrome

N35- Urethral stricture (chronic urinary tract inflammation and infections can cause scarring of the urethra. It narrows the tract causing a delay in bladder emptying. Delayed or improper emptying leads to more infection and inflammation).

N35.1- Postinfective urethral stricture, not classified elsewhere

N35.8- Other urethral stricture

N35.9- Unspecified urethral stricture

N36- Other disorders of the urethra

N36.0- Urethral fistula (recurrent infections cause the weakening and breaking of urethral lining). This code also covers false urethral passage, urethroperineal fistula, urinary fistula, and urethrorectal fistula.

N36.3- Prolapse of urethral mucosa (outpouching of the urethra is complicated by recurrent infections, leading to prolapse). Male urethrocele is covered in this section.

N36.8- Other specified disorders of the urethra

N36.9- Unspecified urethral disorders

N37- Urethral disorders in diseases classified elsewhere

N37.0- Urethritis in diseases classified elsewhere (also includes Candidal urethritis)

N37.8- Other urethral disorders in diseases classified elsewhere

N39.3- Stress incontinence (a complication of UTIs). Additional code N32.8- is used to identify the reason for stress incontinence).

N39.4- Other specified urinary incontinence (includes overflow incontinence, reflex incontinence, and urge incontinence).

N39.8- Other specified disorders of the urinary system

N39.9- Unspecified disorder of the urinary system

Causes of UTI:

UTI occurs when bacteria enter the genitourinary system. The most common bacteria to cause urinary tract infection is Escherichia coli (E.coli). Other pathogens that most likely cause UTIs (like cystitis and pyelonephritis) are Staphylococcus saprophyticus, Klebsiella species, Enterobacter species, and Proteus mirabilis.

Because of their anatomy, urinary tract infection is more common in females than males. Their urethras are shorter and closer to their rectums, making it easier for bacteria to enter the urethra and cause infection. Other factors that can increase the UTI risk are:

• Sexual activities
• Menopause
• Pregnancy
• Enlarged prostate (blocking the urinary tract)
• Birth control (use of diaphragms)
• Spermicidal agents
• Compromised immune system
• Catheters
• Urinary procedures

Symptoms of Urinary Tract Infection:

• Pain with a burning sensation with defecation
• A frequent and strong urge to urinate
• Colored or bloody urine
• The cloudy appearance of the urine
• Smelly urine
• Groin pain and cramps
• Fever with chills
• Vaginal discharge and itching in women
• Malaise and lethargy
• Sweats
• Headache

Important points

• Urinary tract infection(UTI) is commonly used as a synonym for acute cystitis or acute urethritis, although the site of the infection has not been established.
• Before assigning the more specific code, ensure the site is supported with the necessary documentation.
• Choose the primary and secondary diagnosis codes based on the severity of the disease.

ICD-10 UTI Frequently Asked Questions

References:

1. ICD-10 Version:2019; World Health Organisation.

https://icd.who.int/browse10/2019/en#/K20-K31

2. Gupta K, Grigoryan L, Trautner B. Urinary Tract Infection. Ann Intern Med. 2017 Oct 3;167(7):ITC49-ITC64.

https://doi.org/10.7326/AITC201710030

3. Ronald A. The etiology of urinary tract infection: traditional and emerging pathogens. Am J Med. 2002 Jul 8;113 Suppl 1A:14S-19S.

doi: 10.1016/s0002-9343(02)01055-0. PMID: 12113867.

4. Heyns CF. Urinary tract infection associated with conditions causing urinary tract obstruction and stasis, excluding urolithiasis and neuropathic bladder. World J Urol. 2012 Feb;30(1):77-83.

doi: 10.1007/s00345-011-0725-9. Epub 2011 Jul 1. PMID: 21720861.

5. Miano R, Germani S, Vespasiani G. Stones and urinary tract infections. Urol Int. 2007;79 Suppl 1:32-6.

doi: 10.1159/000104439. PMID: 17726350.

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