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Hydronephrosis/infection

Denise Posted Wed 18th of May, 2016 17:54:48 PM
N13.6 obstructive and reflux uropathy/hydronephrosis with INFECTION. What constitutes "with infection"? UTI, pyelonephritis, positive urine cultures, elevated WBCs, "on placement of stent there drainage of dark,foul, purulent urine from the kidney, etc. Not sure when it is correct to use this code. Any guidance for this code? Thank you.
SuperCoder Answered Thu 19th of May, 2016 02:58:12 AM
Hi, first of all please always remember the golden rule: “Not Documented, Not Done”. We should not assume if it is not clear in medical record. It means if it is written in MR that Hydronephrosis is with infection, then code it accordingly. Else it is always better to contact the physician or physician’s clinic and get it clear and it should be documented. This is the safest and correct way to avoid any denial. Now in the case presented by you, you can report Hydronephrosis with infection since there is UTI and pyelonephritis mentioned in the MR. Please feel free to write if you have any concern or query. Thanks

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