Coding, Classification and Reimbursement

N39.0 Urinary tract infection, site not specified

  • 1.  N39.0 Urinary tract infection, site not specified

    Posted 12 days ago
    Hi, someone asked me recently "why does the code say site not specified?" relative to:

    N39.0 Urinary tract infection, site not specified

    I am totally drawing a blank on answering this and would appreciate any feedback!

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    Bill Roush, RHIA, BSHI, AHIMA-Approved ICD-10-CM Trainer
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  • 2.  RE: N39.0 Urinary tract infection, site not specified

    Posted 12 days ago
    Edited by Andrea Wong 12 days ago
    Urinary tract infection (UTI) is a broad general term indicating an infection existing in the urinary tract system. This code is used when no specific site in the urinary tract is documented by the doctor as being affected. Ex: UTI or Pyuria.

    When a specific site is documented or a more specific UTI is documented, N39.0 is not coded. Instead, the specific type of UTI is coded is because coders always code to the most specific diagnosis that is documented.

    Tabular info: The code for N39.0 - UTI, site not specified, has exclude 1 note to code to a specified site such as cystitis (N30-), urethritis (N34-). A UTI can happen also in the kidney, which is also known as pyelonephritis (acute, chronic, unspecified.)

    Specific sites is all about anatomy: urethritis, cystitis, ureteritis, pyelonephritis/pyelitis/nephritis

    Of course the documentation may also be classified by acuity: acute chronic, or unspecified

    Worth mentioning that N39.0 (UTI, unspecified) or any site of urinary tract infection can be inherent with another condition such as Pyonephrosis. Pyonephrosis includes hydronephrosis, kidney stone (when present), and Infection. A UTI code isn’t coded separately, when assigning N13.6 -Pyonephrosis.

    The coding index will guide you to one N13.6 code only. Index: Hydronephrosis > infection > N13.6 . The tabular note under N13.6 will tell you “conditions in N13.0-N13.5 with infection” is included in N13.6 -Pyonephrosis, and code N13.2 (Hydronephrosis with renal and ureteral calculus obstruction), falls within that tabular range, so N13.6 -Pyonephrosis, includes presence of kidney stones and kidney stones aren’t coded separately. Hope this makes sense how complex UTIs can be!

    Happy coding!



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    Andrea Wong
    Coder
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  • 3.  RE: N39.0 Urinary tract infection, site not specified

    Posted 12 days ago
    Hi Bill,

    It is site not specified - because the part of the urinary tract that is infected cannot or was not identified.   For example - cystitis and pyelonephritis are specific parts of the urinary tract that are infected and you wouldn't code those infections along with the N39.0.

    Hope this helps.


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    Carole S. Liebner, RHIT, CDIP, CCS
    AHIMA Approved ICD-10 CM/PCS Trainer
    AHIMA Approved Revenue Cycle Trainer
    Director of Education and Program Development

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