ICD-10 Coding for History of UTI and Prophylactic Antibiotic Use
For an asymptomatic patient with a documented personal history of urinary tract infection, use ICD-10-CM code Z87.440 (Personal history of urinary tract infections), and for long-term prophylactic antibiotic use, add Z79.2 (Long-term [current] use of antibiotics).
Primary Coding for History of UTI
Z87.440 is the specific ICD-10-CM code for personal history of urinary tract infections and should be used when documenting a patient's past UTI history in the absence of current active infection 1.
This code applies when the patient is currently asymptomatic but has a documented history that may be relevant to current care decisions, such as consideration for prophylactic measures 2.
Additional Coding for Prophylactic Antibiotic Use
Z79.2 (Long-term [current] use of antibiotics) should be added as a secondary code when the patient is receiving continuous or postcoital antimicrobial prophylaxis for recurrent UTI prevention 2.
The European Association of Urology guidelines recommend continuous or postcoital antimicrobial prophylaxis to prevent recurrent UTI when non-antimicrobial interventions have failed, which justifies the use of this code 2.
Clinical Context for Code Selection
Recurrent UTI is defined as at least three UTIs per year or two UTIs in the last 6 months, and this clinical context supports the use of both history and prophylaxis codes 2.
The guidelines emphasize that rUTI prevention includes counseling regarding avoidance of risk factors, non-antimicrobial measures, and antimicrobial prophylaxis, with these interventions attempted in the order listed 2.
When NOT to Use These Codes
Do not use Z87.440 if the patient has current, active UTI symptoms (dysuria, frequency, urgency, fever, or gross hematuria), as an acute infection code would be more appropriate 2, 3, 4.
Do not code for UTI history based solely on asymptomatic bacteriuria or pyuria, as these findings do not represent true infection and should not be treated in most populations 5, 6, 7.
Documentation Requirements
Medical record documentation should clearly indicate the history of recurrent UTIs with specific dates or frequency of past infections to support the Z87.440 code 1.
For Z79.2, documentation must specify the prophylactic antibiotic regimen, duration, and indication (prevention of recurrent UTI) 2.
The chart should reflect that non-antimicrobial preventive measures were attempted first, as recommended by guidelines, before initiating long-term antibiotic prophylaxis 2.