Understanding urine analysis diagnosis codes and clinical documentation is crucial for accurate medical coding and billing. This resource provides information on urine analysis interpretation, normal and abnormal urinalysis results, common urine test diagnostic codes, and best practices for healthcare professionals documenting UA findings. Learn about specific gravity, proteinuria, hematuria, leukocyte esterase, nitrites, ketones, bilirubin, urobilinogen, and other key indicators in urine tests for improved patient care and streamlined healthcare operations.
Also known as
Abnormal findings in urine
Includes abnormal results of urine analysis, like proteinuria or hematuria.
Other symptoms and signs involving the urinary system
Covers general urinary symptoms, some of which might prompt a urine analysis.
Diseases of the genitourinary system
Many conditions in this range can cause abnormal urine, leading to analysis.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the urine analysis abnormal?
When to use each related code
| Description |
|---|
| Urine analysis (UA) |
| Urine culture |
| Microalbuminuria test |
Coding urine analysis without specific findings leads to inaccurate reimbursement and data analysis. Use specific ICD-10 codes.
Separate coding of individual components of a complete urinalysis panel can be considered unbundling, violating billing compliance.
Lack of documentation supporting the medical necessity of the urine analysis may lead to claim denials and compliance issues. CDI essential.
Patient presents for urine analysis due to [reason for testing; e.g., dysuria, frequency, urgency, flank pain, routine screening, pre-operative evaluation, monitoring chronic kidney disease]. Symptoms began [onset duration; e.g., two days ago, one week ago, several months]. Patient reports [associated symptoms; e.g., fever, chills, nausea, vomiting, hematuria, abdominal pain, back pain]. Patient denies [relevant negatives; e.g., incontinence, trauma, recent antibiotic use]. Medical history significant for [relevant medical history; e.g., diabetes mellitus, hypertension, kidney stones, recurrent urinary tract infections, pregnancy]. Surgical history includes [relevant surgical history; e.g., nephrectomy, kidney transplant]. Medications include [list medications]. Allergies include [list allergies]. Physical examination reveals [relevant physical exam findings; e.g., costovertebral angle tenderness, suprapubic tenderness, normal abdominal exam]. Urine dipstick analysis demonstrates [dipstick results; e.g., positive leukocyte esterase, positive nitrites, positive blood, positive protein, glucose positive or negative, ketones positive or negative, specific gravity]. Urine microscopic examination shows [microscopic findings; e.g., white blood cells, red blood cells, bacteria, epithelial cells, casts]. Urine culture sent for analysis. Assessment: [Diagnosis; e.g., Urinary tract infection, asymptomatic bacteriuria, hematuria, proteinuria, pyuria]. Plan: [Treatment plan; e.g., prescribe antibiotics, recommend increased fluid intake, refer to urology, order further testing such as renal ultrasound or CT scan, monitor for resolution of symptoms, patient education regarding UTI prevention]. Patient instructed to return for follow-up if symptoms worsen or do not improve within [timeframe; e.g., 48-72 hours, one week]. ICD-10 code: [relevant ICD-10 code; e.g., N39.0, N30.00, R31.9]. CPT code: [relevant CPT code; e.g., 81000, 81002].