2025 ICD-10-CM code N39.0
Urinary tract infection, site not specified.
Medical necessity for using N39.0 rests on the clinician's judgment based on the patient's presenting symptoms, physical examination, and laboratory findings suggestive of a UTI, even if the precise anatomical location within the urinary tract cannot be immediately identified.Further investigation may be necessary in some instances to pinpoint the site and causative agent and determine the most effective treatment strategy.
Clinicians are responsible for identifying the site of the UTI if known and coding it more specifically. The documentation should support the diagnosis and any associated signs/symptoms. It is essential to document the cause of the infection if identified.
In simple words: This code represents a urinary tract infection (UTI) where the specific location within the urinary tract (kidneys, ureters, bladder, urethra) is not specified in the diagnosis.
Urinary tract infection, site not specified. Use additional code (B95-B97) to identify infectious agent.
Example 1: A patient presents with dysuria, frequency, and urgency but the specific location of the UTI is not yet determined. N39.0 is used until further diagnostic testing can pinpoint the site of infection., A patient with a history of recurrent UTIs presents with generalized symptoms.Initial urinalysis suggests infection, but further localization studies are pending. N39.0 is appropriate initially., A patient reports symptoms suggestive of a UTI.Due to time constraints or patient preference, a definitive workup to identify the specific site of infection is deferred, and empiric treatment is initiated. N39.0 can be used in this situation.
Symptoms (dysuria, frequency, urgency, hematuria, etc.), urinalysis results, and any imaging or diagnostic studies performed. If the infectious agent is identified (e.g., E. coli), it should also be documented and coded using an additional code (B95-B97).
** This code is distinct from codes that identify UTIs at specific sites.If the site of infection is known, it should be coded using the more specific code.
- Specialties:Urology, Family Medicine, Internal Medicine, Nephrology, Emergency Medicine
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Emergency Room - Hospital, Skilled Nursing Facility, Nursing Facility,Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home