ICD-10 Code for UTI (Urinary Tract Infection)

Clinical & Billing Overview

Urinary tract infections (UTIs) are among the most common bacterial infections seen in outpatient, urgent care, and emergency settings. From a coding perspective, accuracy matters: ICD-10-CM requires coders to report the most specific diagnosis documented, including the anatomic site, acuity, and any known causative organism. Correct coding directly impacts medical necessity, payer reimbursement, and audit risk.

Primary ICD-10 Code for UTI

N39.0 – Urinary tract infection, site not specified

When to use N39.0:

• The provider documents “UTI” without specifying cystitis, urethritis, or pyelonephritis
• No anatomic site is identified in the clinical note
• Common in initial or uncomplicated encounters, especially in primary care or urgent care

Coding best practice: N39.0 should only be used when the site truly is unspecified. If documentation supports a more specific diagnosis, N39.0 should not be reported.

Related & Alternative ICD-10 Codes

Use a more specific code whenever documentation allows:

• N30.00–N30.01 – Acute cystitis (without/with hematuria)
• N30.90–N30.91 – Cystitis, unspecified (without/with hematuria)
• N10 – Acute pyelonephritis
• N34.1 – Nonspecific urethritis
• N12 – Tubulo-interstitial nephritis, not specified as acute or chronic

Organism-Specific Add-On Codes

If the causative organism is identified, assign an additional code:

• B96.20–B96.29 – E. coli and other bacterial causes
• B95.0–B95.8 – Streptococcus or Staphylococcus species

Documentation Requirements & Coding Rules

To support accurate ICD-10 assignment, documentation should include:

• Anatomic site (bladder, kidney, urethra, unspecified)
• Acuity (acute vs chronic or recurrent)
• Presence of hematuria, if applicable
• Culture results and organism, when known
• Complicating factors (pregnancy, catheter use, comorbidities)

Reminder: Do not code “suspected” or “rule out” UTIs in outpatient settings. Use confirmed diagnoses or documented symptoms.

Services Commonly Supported by UTI Codes

UTI diagnosis codes frequently support medical necessity for:

Diagnostic Tests

• Urinalysis (dipstick or automated)
• Urine culture and sensitivity testing

Procedures & Treatment

• Office or ED evaluation and management (E/M)
• Antibiotic administration or prescription
• IV hydration (when clinically indicated)

Durable Medical Equipment (DME)

• Intermittent or indwelling urinary catheters (when documented)

Follow-Up Services

• Repeat urinalysis or cultures
• Post-treatment evaluation for persistent or recurrent infection

Includes vs Excludes (ICD-10 Guidance)

N39.0 Includes

• Unspecified urinary infection
• UTI not further defined by site

N39.0 Excludes

• Acute cystitis (N30.0-)
• Pyelonephritis (N10)
• Urethritis (N34.1)
• Genitourinary infections with identified site

Common CPT & HCPCS Pairings

Frequently reported services with UTI-related diagnoses include:

• 81000–81003 – Urinalysis, non-automated
• 81001–81015 – Urinalysis, automated
• 87086–87088 – Urine culture
• 99202–99215 – Office or outpatient E/M services
• 96365 – IV infusion therapy (when applicable)
• J0696 – Ceftriaxone sodium injection (example antibiotic)

Always ensure CPT codes align with documented medical necessity and payer policy.

Denial & Audit Risk Reduction Tips

• Avoid defaulting to N39.0 when a specific diagnosis is documented
• Link lab tests and cultures to the UTI diagnosis clearly
• Ensure antibiotics align with diagnosis and severity
• Use organism codes only when lab-confirmed
• Watch for payer edits on recurrent UTIs and repeat cultures

FAQs

What is the ICD-10 code for a UTI?
The most commonly used code is N39.0 – Urinary tract infection, site not specified, when no specific site is documented.

Can N39.0 be used for cystitis?
No. If cystitis is documented, a code from N30.0- or N30.9- should be reported instead.

Do I need an additional code for the bacteria causing the UTI?
Yes, if the organism is identified, assign an additional B95–B96 code.

Is hematuria coded separately with a UTI?
Only if documentation supports it and a combination code is not available (e.g., cystitis with hematuria).

Can UTI codes support urine cultures?
Yes, when testing is medically necessary and linked to the diagnosis.

Summary

Accurate ICD-10 coding for UTIs hinges on specific documentation and proper code selection. While N39.0 remains appropriate for truly unspecified infections, coders should always prioritize site-specific and organism-based codes when available to reduce denials and ensure compliance.