tci ED Coding & Reimbursement Alert - 2002 Issue 7

Reader Question: Catheter Insertion and E/M

Question: A patient presented to the ED complaining of pain during urination. An exam found the patient to have an inflamed urinary tract with an acute kidney infection. The ED physician inserted a catheter to assist in voiding, and administered antibiotics. How should I code this procedure? Nevada SubscriberAnswer: Urinary tract infections (UTIs) fall into two categories: lower-tract bladder infections (cystitis) and upper-tract kidney infections (pyelonephritis). The most common pitfall of coding for UTIs is the ED doctor's failure to document all the information pertinent to the level of E/M he or she chose for the visit. Some doctors...

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