H&P: 78 yr. old female admitted with abdominal pain. Caregiver states the patient is complaining of abdominal pain, and only 75mL of cloudy urine emptied from her suprapubic catheter overnight.
PMH: recurrent UTI, cerebral palsy with chronic contractures, urethral stricture with chronic suprapubic catheter, seizure d/o.
Home medications: Lisinopril po, Loratadine po, Methocarbamol po, Phenobarbital po, Phenytoin po, Simvastatin po
Vitals: Temp 36.2, HR 86, BP 135/74, RR 20, O2 Sat 97%
Labs: WBC 18.6, BUN/cr/GFR 56/1.93/37, UA: appearance hazy, + nitrates, bacteria many; Urine Culture: >100,000 cfu/ml Escherichia coli isolated , WBC 12.7, BUN/cr/GFR 42/1.45/40(Day 2),BUN/cr/GFR 36/1.19/48 (Day 3), BUN/cr/GFR26/1.16/62 (Day 4)
Urology Consult: Pt with h/o recurrent UTI and suprapubic catheter, suprapubic discomfort.
Nursing assessment: Maximum assistance with ADLS, Braden score range 10-12
Discharge Summary: Patient admitted with abnormal UA suprapubic catheter changed by Urology. IV ATB switched to PO at D/C. Dehydration resolved with IVF.
Discharge Medication: Augmentin 500mg po
Question: Are there query opportunities based on the scenario stated above?
Discussion: Patient with indicators of UTI due to suprapubic catheter (CAUTI)
Diagnostic criteria for CAUTI:
- H/o recurrent urinary tract infections, urethral stricture with chronic suprapubic catheter
- patient c/o abdominal pain
- 75 ml cloudy urine emptied from suprapubic catheter prior to admission
- Documentation of abnormal UA on discharge summary
- UA results: appearance hazy, + nitrates, bacteria many
- Urine Culture: >100,000 cfu/ml Escherichia coli isolated
Treatment for CAUTI:
- Suprapubic catheter changed by Urology
- Treatment: Ceftriaxone IV, Suprapubic catheter flushed
UASI Recommends:
Query for the urinary tract infection due to suprapubic catheter, acute kidney injury, and spastic quadriplegia related to cerebral palsy.
Documentation without clarification:
Principal Diagnosis: Unspecified abnormal findings in urine (R82.90)
Secondary Diagnosis: Cerebral Palsy (G80.8) Dehydration (E86.0)
Working DRG: 696 Kidney and urinary tract signs and symptoms without MCC
RW: 0.693 GLMOS: 2.3 SOI/ROM: 1/1
Documentation with clarification:
Principal Diagnosis: Infection and inflammatory reaction due to other urinary catheter, initial encounter (T83.518A)
Secondary Diagnosis: Cerebral palsy (G80.8); Dehydration (E86.0); Acute kidney failure, unspecified (N17.9); Spastic Quadriplegia (G80.0) UTI (N39.0)
Working DRG: 698 Other kidney and urinary tract diagnoses with MCC
RW: 1.6025 GLMOS: 4.8 SOI/ROM: 2/2
CDI Educational Tips:
- Code assignment (T83.518A) depends upon provider documentation of a UTI, and if it was due to or associated with a urinary catheter.
- If the condition, catheter-associated urinary tract infection, is not POA it is classified as a hospital acquired condition (HAC).
- A provider query is appropriate if the documentation is unclear as to whether the condition is present on admission (POA).
Pinson and Tang
- Evidence of AKI (creatine steadily decreased meeting KDIGO criteria of increase greater or equal to 1.5X baseline within prior 7 days)
- Spastic quadriplegia (cerebral palsy with contractures caused by a medical condition without physical injury or damage to the spinal cord)
Symptoms and Signs of CAUTI:
- Patients with catheter-associated urinary tract infection (CAUTI) cannot have some of the symptoms typical of UTI’s (dysuria, frequency), but they may complain of feeling the need to urinate or of suprapubic discomfort. However, such symptoms of lower UTI may also be caused by obstruction of the catheter or development of bladder calculi.
Merck manual
- Physicians often use the term “urinary tract infection” (UTI) when referring to conditions such as urethritis, cystitis, or pyelonephritis. Urethritis and cystitis are lower urinary tract infections; pyelonephritis is an infection of the upper urinary tract.
AHA Coding Handbook
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.