CODES.AND.STUFF

Q.    What are the correct ICD-10 codes to assign for a patient who is admitted for a DMSA (Dimercaptosuccinic acid) scan following a previous Urinary Tract Infection (UTI), which has now resolved following treatment with antibiotics?

A.    A DMSA scan is a form of renal scintigraphy also known as a static renogram. This scan gives information about the size, shape and position of the kidneys, and whether there are scars on the kidney from a previous infection such as a UTI.

Provided the patient has no current symptoms and no abnormalities are found during the DMSA scan, the correct ICD-10 codes to assign are:

Z09.2 Follow-up examination after chemotherapy for other conditions

Z87.4 Personal history of diseases of the genitourinary system

It is appropriate to assign the ICD-10 code Z09.2 Follow-up examination after chemotherapy for other conditions, to reflect the previous antibiotic treatment. The term chemotherapy pertains to any drug therapy and therefore, as the patient has previously received antibiotics for the treatment of the UTI, it is correct to assign this ICD-10 code in the primary position.

This guidance can also be applied to other diagnostic procedures such as cystoscopy, ureteroscopy, and endoscopic retrograde pyelography when these procedures have been specifically performed following a previous UTI, which has now resolved following treatment with antibiotics.

Date published: 06/2010 (Volume 7 Issue 3)

Coding Clinic, NHS Classifications Service

www.connectingforhealth.nhs.uk/codingclinic

Tags: dmsa, uti, z codes