ICD-10 Coding for Asymptomatic Bacteriuria
The ICD-10 code for asymptomatic bacteriuria is N39.0 (Urinary tract infection, site not specified).
Primary Code Assignment
- N39.0 is the most appropriate code for asymptomatic bacteriuria, as ICD-10 does not have a specific code that distinguishes asymptomatic from symptomatic bacteriuria 1.
- This code falls under the broader category of "Other disorders of urinary system" (N39) and is used when bacteria are present in urine without clinical symptoms 1, 2.
Important Coding Considerations
When Documentation Matters Most
- Ensure clear documentation that the patient is truly asymptomatic—meaning no dysuria, frequency, urgency, suprapubic pain, fever, or costovertebral angle tenderness 1.
- If any urinary symptoms are present, the condition should be coded as symptomatic UTI rather than asymptomatic bacteriuria 1.
Population-Specific Coding Context
- For pregnant women with asymptomatic bacteriuria, consider adding O23.4- (Unspecified infection of urinary tract in pregnancy) as this population requires screening and treatment 1, 2, 3.
- For patients with indwelling catheters, document catheter-associated bacteriuria separately, as this affects clinical management decisions 1.
- For patients undergoing urologic procedures, document the pre-procedural screening context, as treatment is indicated before endoscopic procedures with mucosal trauma 1.
Common Coding Pitfalls to Avoid
- Do not code based on pyuria alone—the presence of white blood cells in urine without quantitative bacterial counts does not constitute asymptomatic bacteriuria 1, 4.
- Avoid coding asymptomatic bacteriuria as cystitis (N30.-) or pyelonephritis (N10), which are reserved for symptomatic infections 1.
- Do not use R82.71 (Bacteriuria) as the primary diagnosis when asymptomatic bacteriuria is the clinical condition being documented, as N39.0 is more specific for the urinary tract infection context 1.
Documentation Requirements for Accurate Coding
- Quantitative urine culture results should be documented: ≥10^5 CFU/mL for voided specimens in women (two consecutive samples) and men (single sample), or ≥10^2 CFU/mL for catheterized specimens 1, 4.
- Explicit statement of absence of symptoms referable to the urinary tract should be included in the medical record 1, 2.
- Specific bacterial organism identified should be documented when known 4.