Urinary tract infections or UTIs are the infections in the lower urinary tract, specifically in the bladder or the urethra. UTIs are one of the most common types of infections mainly affecting young adults, especially women. Risk factors that generally lead to a urinary tract infection include use of spermicidal agents or diaphragms, structural abnormalities of the urinary tract and even sexual activity. UTIs are easily treated with antibiotics, but if left untreated, the infection can go up the tract and affect the kidneys.
Urinary tract infections affect millions of people each year. As per the Centers for Medicare and Medicaid Services, UTIs are the single most common hospital-acquired infection that accounts for over a million cases in the US. The sheer number of cases and the implementation of MS-DRG makes the correct coding and assignment of UTIs more important than ever.
UTI Clinical Information
A bacterial infection that affects any part of the urinary tract is classified as a UTI. Kidneys, bladder, ureters, and the urethra make up the urinary system and its infections are one of the most common types of infections in the body. To give a more precise definition a UTI is an inflammatory response of the epithelium in the urinary tract to microbial invasions. They are often bacterial infections with associated bacteriuria and pyuria.
Common symptoms include:
- pain or burning when you use the bathroom
- fever, tiredness, or shakiness
- an urge to use the bathroom often
- pressure in your lower belly
- urine that smells bad or looks cloudy or reddish
- less frequently, nausea or back pain
Types of UTI
– Cystitis: This is an inflammation or infection in the urinary bladder. Cystitis is caused when bacteria infect the lower urinary tract, causing it to become inflamed and irritated. Pelvic pressure, pain during urination and abdomen discomfort are some of the symptoms that identify cystitis.
– Pyelonephritis: This UTI is characterized by upper back and flank pains, high fever, vomiting, nausea, and headache. Pyelonephritis or pyelitic happens when the infection that starts from the bladder spreads to the kidneys.
– Urethritis: A urinary tract infection in the urethra, characterized by dysuria, urethral discharge, and frequent urination.
Causes of UTI
Urinary tract infections are primarily caused when bacteria find a way into the urinary tract through the urethra and then reside in the bladder, multiplying exponentially. The urinary system has its own defense mechanism to keep out these microbial invasions but is not always successful. When bacteria is able to surpass the defenses, it leads to an infection in any part of the urinary tract, occurring commonly in women.
Diagnosing a UTI
To begin with, healthcare providers take a sample of urine to find out bacteria and the amount of white bold, red blood cells in the sample. To diagnose and interpret frequent infections, a physician may need a computerized tomography, an ultrasound, or a magnetic resonance imaging (MRI) of the urinary tract.
Some physicians also use a contrast dye to get a view of the structures in the tract and perform a cystoscopy to view inside the bladder and urethra. Cystoscopy involves a thin, long tube with a lens called a cystoscope.
Treatment of UTI
The first course of action in the treatment of a urinary tract infection is often antibiotics. For pain relief during urinating, your physician may prescribe an analgesic as well. For some infections, intravenous antibiotics may also be administered at the hospital.
Where antibiotics are proven to be highly effective against infections, they also come with their own side-effects. From mild side-effects such as a minor rash to more serious effects like diarrhea and severe damage to the colon.
ICD 10 Code Set
ICD-10 (short for International Classification of Diseases, tenth edition) is a clinical documentation and cataloging system owned by the World Health organization which consists of thousands of codes, where each code represents critical information about the different diseases, findings, causes of injuries, symptoms, possible treatments, and epidemiology, playing a vital role in enabling advancements in clinical treatment and medication.
Under the Health Insurance Portability and Accountability Act (HIPAA), it is required by all healthcare providers and physicians to apply the ICD-10 codes in their practices, replacing the previous ICD-9 code set.
ICD serves as a foundation to identify clinical trends and statistics globally. Diseases, injuries, disorders, and all health conditions are listed comprehensively and organized into standard groupings allowing health care providers from around the world to compare and share information using the ICD codes.
ICD-10 code for UTI
In order to code precisely for UTIs, a thorough knowledge of the ICD-10-CM Official Guidelines for Coding and Reporting is required, especially the Chapter 14 regarding the Diseases of the Genitourinary System. Codes for the several urinary tract infections can be found in different blocks of the guideline in the Chapter 14.
Codes for pyelonephritis are found in block N10-N16, Renal tubulointerstitial diseases, under categories N10-N12:
N10 Acute pyelonephritis
N11 Chronic tubulo-interstitial nephritis
N12 Tubulo-interstitial nephritis, not specified as acute or chronic
N10 and N12 are billable codes; however, N11 requires requires a 4th digit to describe the condition in more detail, such as:
N11.0, Nonobstructive reflux-associated chronic pyelonephritis
N11.1, Chronic obstructive pyelonephritis
N11.8, Other chronic tubulointerstitial nephritis
N11.9, Chronic tubulointerstitial nephritis, unspecified
Codes for cystitis are found in block N30-N39, Other Diseases of the Urinary System, under category N30, Cystitis. N30 is further classified into these subcategories:
N30.1, Interstitial cystitis (chronic)
N30.2, Other chronic cystitis
N30.4, Irradiation cystitis
N30.8, Other cystitis
N30.9, Cystitis, unspecified
The above are not billable codes and instead require a 5th digit to describe the condition in more detail. Each child code describes either “without hematuria” or “with hematuria.”
For example, N30.0 has two child codes, N30.00 and N30.01:
N30.00, Acute cystitis without hematuria
N30.01, Acute cystitis with hematuria
Codes for urethritis are located in category N34, Urethritis and urethral syndrome, and are further classified into these codes:
N34.0, Urethral abscess
N34.1, Non Specific urethritis
N34.2, Other urethritis
N34.3, Urethral syndrome, unspecified
f the documentation does not state the site of the infection for the UTI, assign:
N39.0, Urinary tract infection, site not specified
N39.0 is listed under category N39, Other disorders of the urinary system.
A thing to take note here is that urinary tract infections should not be coded based on the lab results alone. In case of improper handling and storage, the urine samples are subject to contamination and may give results which are false. It is, therefore, imperative to verify and confirm the diagnoses with your healthcare physician to avoid any inconvenience throughout the billing process.