K52.9 - Noninfective gastroenteritis and colitis, unspecified

Clinical Definition

A urinary tract infection (UTI) occurs when bacteria enter and multiply in any part of the urinary system, most commonly affecting the bladder and urethra. The infection can be either lower tract (bladder/urethra) or upper tract (kidneys).

Documentation Requirements

• Location/Site:

  • Specify if lower tract (cystitis) or upper tract (pyelonephritis)

  • Document specific anatomical location (bladder, urethra, kidney)

  • Note if catheter-associated

• Acuity:

  • Acute vs chronic

  • First episode vs recurrent

  • Duration of symptoms

• Organism/Cause:

  • Document causative organism if known

  • Note if drug-resistant

  • Include culture results when available

• Associated Conditions:

  • Pregnancy status if applicable

  • Diabetes or other risk factors

  • Presence of urinary stones

Common Synonyms

• Bladder infection

• Kidney infection

• Water infection

• Cystitis

• Urine infection

• Bacterial bladder infection

Coding Conflicts

Excludes1:

• Urethritis (N34.-)

• Sexually transmitted UTI (A50-A64)

• Candidal UTI (B37.4-)

Excludes2:

• Pyuria (R82.81)

• Urinary incontinence (N39.3-N39.4-)

Scribing.io Automation

Our AI system automatically identifies:

• Anatomical references (bladder, kidney, urethra)

• Symptom descriptions (dysuria, frequency, urgency)

• Lab results (positive urine culture, WBC count)

• Treatment plans (antibiotics prescribed)

• Chronicity indicators (acute, chronic, recurrent)

The system flags missing elements needed for optimal coding, such as organism identification or specific anatomical location if not mentioned in the note.