General Question for the Week of February 1, 2016

General Compliance Question of the Week

Question:

Documentation shows “mild pyuria,” and the patient was given IV Rocephin. “UTI” is not documented anywhere. Since “pyuria” indexes to unspecified UTI, is this correct? (It is a CC and will increase reimbursement). Its just so strange because in I-9 “pyuria” indexed to abnormal findings in urine.

Answer:

Pyuria is pus in the urine. When you look this condition up in the ICD-10-CM Index, the entry directs the coder to N39.0, and, in answer to your question, the correct code for pyuria in ICD-10-CM is N39.0.

The parentheses after this code indicate that bacterial is a non-essential modifier. N39.0 is the code that is used for UTI, site not specified. There is also an instructional note to use an additional code from B95–B97 to indicate the infectious agent.

Note that you will find many entries that are different between ICD-9-CM and ICD-10-CM. The old terms have been re-evaluated and perhaps the coded condition will change. For example, in ICD-9-CM the term “urosepsis” had a default code of 599.0 which was the code for UTI. In ICD-10-CM, the term “urosepsis” tells the coder to code the condition. This entry identifies that the term “urosepsis” is not clear enough to determine what condition should be coded – UTI or sepsis.

According to the preamble of the 2016 ICD-10-CM Official Coding and Reporting Guidelines, “The instructions and conventions of the classification take precedence over guidelines.” This information tells us that we should follow the Index and the Tabular first.    

 

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.