Knowledge Base Article

Have you ever questioned whether a patient actually has a UTI or not, based on the clinical signs and symptoms documented in the medical record, even if “UTI” is documented by the physician? In this week’s article, we'll be discussing UTIs in more specified detail to help with this very issue, as well as CKD.

UTI

Lab Results

We all should be aware that urine cultures growing greater than 100,000 colony forming units (CRU/mL) usually indicates that an infection is present.

Sometimes an infection, if symptoms are present, may be indicated with lower numbers (1,000 to 100,000 CFU/mL).

If a patient has a urine sample collected with a catheter, which minimizes contamination, results of 1,000 to 100,000 CFU/mL may be considered significant.

Symptoms of a UTI

• Painful urination
• Frequent urination
• Urine that is cloudy, bloody, or has an odor
• Pain and pressure in the pubic bone area (women) and rectal pressure (men)
• Feeling of a full bladder but only have drops of urine on urination
• Tiredness
• Weakness
• Fever if the UTI has spread to the kidneys or blood
• Fever is not common with a UTI of the lower urinary tract (urethra or bladder)

NOTE FROM 2Q Coding Clinic, page 20

The provider must clearly document the causal relationship between the UTI and catheter. A coder cannot automatically assign a Catheter-Associated Urinary Tract Infection (CAUTI) when the patient has an indwelling catheter and then develops a UTI.

However, preventing and tracking CAUTIs is very important so if a patient has an indwelling catheter and a UTI, the coder should query the provider as to the cause of the UTI. This information should be documented in the record, as well.

UTI’s in the Elderly

TIP

Look for catheter use in the elderly.

Symptoms can appear non-specific and a diagnosis may be more difficult to determine in the elderly population and/or for those patients in healthcare settings requiring long-term catheter use.

UTI Due to a Catheter--See Complication, catheter, urethral, indwelling, infection and inflammation in the alphabetic index.

• ICD-9--(996.64)
• ICD-10—(T83.51X_) (seven characters)
• initial encounter
• subsequent encounter
• sequela

Contaminant

Remember, if a UTI is documented and the urine sample grows >100,000 colonies, but is labeled as contaminated, no UTI code is reported.

Something You May Not Know

• Females get UTIs more frequently than males.
• For patients that have frequent UTIs, their bacteria may become resistant to antibiotics over time.
• Patients may be more prone to recurring UTIs if the following are present:
• Kidney disease
• Diseases that affect the kidneys, i.e. Diabetes, Hypertension, etc.
• Compromised immune systems

Chronic Kidney Disease

Chapter 14: Disease of Genitourinary System (I-10)-Coding Guidelines

(Unless otherwise indicated, these guidelines apply to all health care settings)

1. Stages of chronic kidney disease (CKD)
   
   The ICD-10-CM classifies CKD based on severity. The severity of CKD is designated by stages 1-5. Stage 2, code N18.2, equates to mild CKD; stage 3, code N18.3, equates to moderate CKD; and stage 4, code N18.4, equates to severe CKD. Code N18.6, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD).
   
   If both a stage of CKD and ESRD are documented, assign code N18.6 only.
   
   
2. Chronic kidney disease and kidney transplant status
   
   Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0, Kidney transplant status. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.
   
   
3. Chronic kidney disease with other conditions
   
   Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the Tabular List.

See I.C.9. Hypertensive chronic kidney disease

See I.C.19. Chronic kidney disease and kidney transplant complications

NOTE FROM 3Q Coding Clinic, page 3

Complications of a transplanted organ are assigned when the transplanted organ is being rejected by the recipient or there are other complications or diseases of the transplanted organ. Ex: A patient develops Acute Renal Failure after a transplant. If the post-transplant condition affects the function of the transplanted organ, two codes are required. One for the Complication of the Transplanted Organ (996.81) (T86.12), which is sequenced as the principal diagnosis, and a second code describing the Acute Renal Failure (584.9) (N17.9).

Pre-existing conditions or medical conditions that develop after a transplant are coded as Complications of the Transplanted Organ only when they affect the function of that organ.

Status code V42.0 should only be used if there is no complication of the organ replaced. A V42.x status code is never used in conjunction with a (996.8x) code if there is no complication of the same transplanted organ.

Sometimes there are no easy solutions when it comes to coding. After all record documentation has been thoroughly reviewed and analyzed there may be only one solution left. When in doubt, query the physician. The worst that can happen is the physician says ‘no’, right?

Resources:

American Association for Clinical Chemistry

ICD-10-CM Coding Book by Ingenix

AHIMA ICD-10-CM Training Manual

Medicine.Net