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N39.0
ICD-10-CM
E. coli Urinary Tract Infection

Learn about E. coli Urinary Tract Infection (UTI) diagnosis, including clinical documentation and medical coding for Escherichia coli UTI and E. coli bladder infection. Find information on healthcare best practices, symptoms, treatment, and ICD-10 codes related to E. coli UTIs for accurate medical records and billing. This resource supports healthcare professionals in effectively managing and documenting E. coli urinary tract infections.

Also known as

Escherichia coli UTI
E. coli bladder infection

Diagnosis Snapshot

Key Facts
  • Definition : Infection of the urinary tract, most commonly the bladder and urethra, caused by the bacteria Escherichia coli.
  • Clinical Signs : Frequent urination, burning sensation when urinating, cloudy or bloody urine, pelvic pain, back pain or flank pain.
  • Common Settings : Community-acquired, hospital-acquired (nosocomial), nursing homes, catheter-associated.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC N39.0 Coding
N39.0

Urinary tract infection, site not specified

Infection of the urinary tract, exact location unspecified.

N30-N39

Other diseases of the urinary system

Various urinary system disorders excluding infections.

B96.2

Escherichia coli [E. coli] as the cause of diseases classified elsewhere

E. coli infection affecting a system other than the urinary tract.

A00-B99

Certain infectious and parasitic diseases

Broad category encompassing various infectious and parasitic illnesses.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the UTI confirmed as caused by E. coli?

Code Comparison

Related Codes Comparison

When to use each related code

Description
E. coli UTI
Uncomplicated UTI
Cystitis

Documentation Best Practices

Documentation Checklist
  • E. coli UTI confirmed by urinalysis and culture.
  • Document patient signs/symptoms: dysuria, frequency, urgency.
  • Onset and duration of UTI symptoms.
  • Document any prior UTI history or relevant comorbidities.
  • Treatment plan: antibiotics, dosage, and duration specified.

Coding and Audit Risks

Common Risks
  • Unspecified UTI Site

    Coding E. coli UTI without specifying upper or lower urinary tract (e.g., cystitis, pyelonephritis) can lead to rejected claims and inaccurate data.

  • Sepsis Miscoding

    If urosepsis is present, it needs a separate code. Coding only E. coli UTI without the sepsis code can underrepresent severity.

  • Clinical Validation

    Lack of documentation supporting E. coli as the causative organism (e.g., urinalysis) can lead to coding queries and denials.

Mitigation Tips

Best Practices
  • Hydrate well: Drink plenty of fluids to flush bacteria.
  • Hygiene first: Proper perineal care front-to-back.
  • Urinate after sex: Helps clear bacteria from urethra.
  • Cranberry power: Consider cranberry products for prevention.
  • Avoid irritants: Limit caffeine, alcohol, scented products.

Clinical Decision Support

Checklist
  • Verify positive urine culture for E. coli (ICD-10-CM N88.0).
  • Confirm symptoms: dysuria, frequency, urgency (SNOMED CT 48721007).
  • Rule out alternative diagnoses: pyelonephritis, vaginitis.
  • Assess patient risk factors: age, sex, comorbidities.

Reimbursement and Quality Metrics

Impact Summary
  • E. coli UTI diagnosis coding impacts reimbursement through accurate reflection of severity and resource utilization.
  • Correct E. coli UTI coding improves quality metrics reporting for hospital-acquired infections and sepsis rates.
  • Accurate E. coli UTI diagnosis codes enhance data analysis for antibiotic stewardship and resistance tracking.
  • Proper coding of E. coli UTI impacts physician performance profiling and value-based care reimbursement.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Frequently Asked Questions

Common Questions and Answers

Q: What are the most effective evidence-based treatment strategies for recurrent E. coli urinary tract infections in female patients resistant to first-line antibiotics?

A: Recurrent E. coli UTIs in women resistant to first-line antibiotics pose a significant clinical challenge. Evidence-based treatment strategies include: utilizing antibiotic susceptibility testing to guide therapy, considering prolonged low-dose antibiotic prophylaxis (e.g., nitrofurantoin, trimethoprim-sulfamethoxazole), evaluating for anatomical abnormalities contributing to recurrence (e.g., vesicoureteral reflux), and exploring non-antibiotic approaches like vaginal estrogen therapy in postmenopausal women or methenamine hippurate. Furthermore, assessing patient adherence to prescribed regimens and providing thorough patient education on preventive measures (e.g., hydration, hygiene) are crucial. Explore how integrating urine cultures and antimicrobial stewardship principles can optimize treatment outcomes in these complex cases.

Q: How can clinicians differentiate between uncomplicated and complicated E. coli urinary tract infections to ensure appropriate management and avoid treatment failure?

A: Distinguishing between uncomplicated and complicated E. coli UTIs is crucial for effective management. Uncomplicated UTIs typically occur in healthy, non-pregnant females without structural or functional urinary tract abnormalities. Complicated UTIs, however, involve factors that increase the risk of treatment failure, such as male gender, pregnancy, urinary tract obstructions (e.g., stones, catheter), diabetes, immunosuppression, or recent instrumentation. Clinicians should consider patient history, physical examination findings, and urine culture results to make the appropriate distinction. Consider implementing a standardized diagnostic approach incorporating risk stratification to guide antibiotic selection, treatment duration, and follow-up. Learn more about the specific risk factors and clinical presentations associated with complicated UTIs to optimize patient care.

Quick Tips

Practical Coding Tips
  • Code N39.0 for E. coli UTI
  • Document UTI symptoms clearly
  • Specify infection site (e.g., bladder)
  • Consider additional codes for sepsis
  • Check ICD-10-CM guidelines for E. coli

Documentation Templates

Patient presents with symptoms consistent with an E. coli urinary tract infection (UTI), also known as an Escherichia coli UTI or E. coli bladder infection.  Symptoms include dysuria, urinary frequency, urgency, and suprapubic pain.  Patient reports no fever, chills, or flank pain, suggesting uncomplicated cystitis rather than pyelonephritis.  Urinalysis reveals positive leukocyte esterase and nitrites, indicative of a bacterial infection.  Microscopic examination shows significant pyuria and bacteriuria.  Urine culture pending to confirm Escherichia coli as the causative organism.  Differential diagnoses considered included interstitial cystitis, urethritis, and sexually transmitted infections.  Assessment points towards an uncomplicated E. coli UTI.  Plan includes initiating empiric antibiotic therapy with nitrofurantoin, patient education on proper hydration and hygiene practices, and follow-up urinalysis and culture results.  ICD-10 code N39.0 will be used for urinary tract infection, site not specified.  Medical decision making complexity is low.  Patient advised to return if symptoms worsen or do not improve within 48-72 hours.  Patient understands and agrees with the plan.
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