Urinary tract infection (UTI) is a severe health problem that affects millions of people every year. A common type of infection in the body, it can also be a hospital-acquired infection. Not all patients show symptoms though most of them have some symptoms. Also, each type of UTI shows more specific signs and symptoms depending on the part of the urinary tract that gets infected. ICD-10 documentation of this condition is highly specific and must be accurately done. Physicians can consider EHR integrated urology transcription services to ensure accurate medical coding, high productivity and increased revenue. All patient encounters will be documented comprehensively.
Key Concepts in ICD-10 Documentation
- Stage or grade of disease – You should specify the stage of UTI after a thorough examination.
- Severity – Specify the severity, whether mild, moderate or severe.
- Specific anatomic location – The site of the UTI should be specified properly, if known (for example, bladder, urethra, kidney).
- Actual form of UTI – Specify in which form UTI manifests in patients (for example, whether acute or chronic.
- Episode of Care – Specify the episode of care or phase of treatment, whether initial, subsequent or sequel.
- Condition – Specify whether unilateral or bilateral condition.
ICD-10 Documentation – Best Practices
- Ensure whether UTI was present on admission (POA). If it is not clear whether the condition was POA, state that in your documentation
- Link UTI to associated causes or conditions, by using the phrases “due to”, “with” or “secondary to”
- Link UTI to a device, by using the phrases “due to” or “with”
- Lists, commas and the word “and” do not link conditions
- Connect the suspected organism to the infection
- Clarify whether the patient got infected from UTI or Sepsis
- Identify cystitis as being acute, chronic obstructive, interstitial, trigonitis, irradiation, or other form
- Identify pyelonephritis as being acute, chronic, obstructive and reflux uropathy, or drug and heavy metal induced
- Specify when hydronephrosis is accompanied by urethral stricture, reflux nephropathy, calculus obstruction or hydroureter
- Give evidence of any hematuria
Electronic health records or EHRs help you to document all the specific details quickly and give you better access to the required information. However, copy-paste errors and limitation to narrative description may overshadow EHR benefits and your documentation may not be as specific as required. In EHR transcription, experienced and skilled transcriptionists transcribe the physician recordings and review the transcribed data before populating those data within EHR fields via discrete reportable transcription (DRT) technology. By relying upon an efficient medical transcription company, you can enjoy the benefits of EHR integrated transcription and ensure specific and accurate documentation as per your need.