ICD-10 Code for UTI

Content reviewed by Ann Dietrich, MD, FAAP, FACEP.

Key ICD-10 codes for UTIs 

Urinary tract infections (UTIs) impact the urinary system, including the bladder, kidneys, ureters, and urethra. As a nurse, understanding the appropriate ICD-10 codes for UTIs is crucial for accurate documentation, treatment planning, and communication within the healthcare team. Here, we delve into the key ICD-10 codes for UTIs, their definitions, and their nursing applications. 

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

Description: This code is used for a general diagnosis of a urinary tract infection when the specific site of the infection is not identified. 

Nursing application: Nurses should be aware of the nonspecific symptoms of a UTI, such as dysuria, frequent urination, and urgency, but the specific location of the infection (e.g., bladder or kidney) has not been determined. Accurate documentation of the patient’s presentation is essential to guide appropriate initial treatment and further diagnostic testing. 

2. N30.00 - Acute cystitis without hematuria 

Description: Acute cystitis refers to a sudden onset of bladder inflammation, typically caused by a bacterial infection, without the presence of blood in the urine. 

Nursing application: Nurses should be vigilant in assessing and documenting symptoms such as suprapubic pain, increased frequency, and urgency of urination. They should also educate patients on completing the full course of prescribed antibiotics to prevent recurrence and complications. 

3. N30.01 - Acute cystitis with hematuria 

Description: This code is for acute cystitis that presents with hematuria, or blood in the urine. 

Nursing application: Nurses need to monitor patients for signs of hematuria, which can indicate a more severe infection or other underlying conditions. Prompt documentation and communication with the healthcare team are vital to ensure timely intervention and treatment adjustments. 

4. N10 - Acute pyelonephritis 

Description: Acute pyelonephritis is a sudden and severe kidney infection that can result from a bacterial infection ascending from the lower urinary tract. 

Nursing application: For patients diagnosed with acute pyelonephritis, nurses should monitor for symptoms such as fever, flank pain, nausea, and vomiting. Nurses should also monitor vital signs and alert the healthcare team for any signs of sepsis. They should ensure patients receive appropriate antibiotic therapy and provide education on signs of complications, emphasizing the importance of follow-up care. 

5. N30.90 - Cystitis, unspecified without hematuria 

Description: This code covers cases of cystitis where the specifics, such as whether hematuria is present, are not detailed in the diagnosis. 

Nursing application: Nurses should document general symptoms of cystitis and work with the healthcare team to determine if further testing is required to specify the nature of the cystitis. Patient education on hydration and hygiene practices to prevent future infections is also essential. 

6. N30.91 - Cystitis, unspecified with hematuria 

Description: This code is used when a patient is diagnosed with cystitis and hematuria is present, but other specifics of the condition are not provided. 

Nursing application: Nurses should ensure thorough documentation of hematuria and assess for potential causes and complications. Coordination with the healthcare team for comprehensive care and patient education on managing symptoms and preventing recurrence is crucial. 

Nursing considerations and best practices 

Assessment and documentation 

• Accurate and detailed documentation of symptoms, patient history, and diagnostic results is essential for effective treatment and management of UTIs. 
• Assess vital signs and alert the healthcare team of any signs of sepsis. 
• Be aware of the ICD-10 codes based on the clinical presentation and diagnostic findings. 

Patient education 

• Educate patients on the importance of completing antibiotic courses, maintaining adequate hydration, and practicing good urinary hygiene. 
• Discuss lifestyle modifications that can help prevent UTIs, such as urinating after sexual intercourse and avoiding irritants like harsh soaps. 

Symptom management 

• Provide comfort measures such as heating pads for abdominal or back pain. 
• Encourage patients to drink plenty of fluids to help flush out bacteria from the urinary tract. 

Follow-up care 

• Stress the importance of follow-up appointments to ensure the infection has cleared up and to check for any potential complications. 
• For recurrent UTIs, consider discussing with the healthcare provider the possibility of further investigations to identify underlying causes. 

Resources

For further reading and references, please consult the following resources: 

• World Health Organization ICD-10 Version:2019 
• Centers for Disease Control and Prevention - Urinary Tract Infection (UTI) 

By staying informed and proactive, nurses can positively impact the quality of care provided to patients suffering from UTIs.