Our providers are doing the urine dip order with a symptom such as R30.0. When the dip comes back positive and the provider states UTI in the encounter, do we use N39.0 for the encounter and change the lab to match, or add the symptom diagnosis to the claim along with N39.0 in order to cover the ordered lab? Technically, the symptom should not be listed if the patient has a UTI and N39.0 is used, but then we really shouldn’t be changing the labs ordered by the providers.

I did find something from 2014 that states we should use the symptoms only as the results would not be completed at the time of visit, but from what I can see in our recs, it looks like the result may be back that soon.

Help!

Anne