UTI not noted by attending

tkreilingtkreiling
in CDI Talk Archive
Does anyone have any advice on how to handle this scenario. A pt was sent to the ER from nursing home because of abnormal labs and jaundice and was then admitted to inpt for work up. ER physician documented UTI (cx ended up grow out 100,000 proteus mirabilis) the attending never writes UTI, pt was on Zosyn (also had pancreatitis)which urine cx was sensitive to. I did a verbal query to the physician that ER dx of UTI but no further mention of UTI . He told me he didn't think the pt had a UTI and would look at the chart. Pt was discharged the next day and there is no mention of UTI in discharge summary. The coder is now trying to code the chart and is asking me to requery the physician,any advice on how to approach this?
Thanks!

Comments

  • cmorellcmorell
    We list the clinical indicators such as the + blood cultures and labs etc and the medication being given and query:

    What is the diagnosis for which these resources are being utilized?
  • digardskdigardsk
    edited May 2016
    Your ED physician dxed the UTI, and it was treated during the stay. UTI not negated by attending. I think it could be coded.


  • robert.hodges2robert.hodges2
    edited May 2016
    I'd go along with this. Something was being treated. I've also asked the significance of the urine culture. For consistency the provider should be following up and document that they ruled out the UTI and then document what they were treating.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens


  • Unknown
    edited May 2016
    Since the diagnosis of UTI is documented by ER physician and Zosyn was given, I'd be inclined to use it.
    However, if you are unsure you could query, for example:

    Urine C&S shows proteus mirabilis sensitive to Zosyn. Pt received Zosyn IV on ( ) dates. Could you please render your opinion on the clinical significance of this patient's abnormal urine culture and the diagnosis for which the Zosyn IV was given? Thank-you.


    Charlene


  • NormaBNormaB
    edited May 2016
    If you spooke nto the attending reagarding the mention of nthe UTI and he said he didn't think the patient had a UTI V no mention in the Discharge Summary says he doesn't think the UTI was present.

    You could query for an addendum to the Discharge Summary - "in addendum the ER physician felt patient had UTI and started patient on Zosyn," or "patient had a UTI Present on admission which was treated by Zosyn" or "but I do not believe the patient had UTI."

    If she is looking for a CC you may risk losing it if the RAC reviews the chart by querying after discharge.

    But the ER physician is a physician and we take his documentation as codeable.

    Its like a person who comes in the ER in congestive heart failure and Lasix is administered.

    Just because the patient's CHF was stable for the rest of the admission does not mean the patient did not have an Acute incident and should not be coded if the ER doc says Acute.

    N. Brunson, RHIA, CCDS


  • sbeattysbeatty
    edited May 2016
    He's the doctor and makes the diagnoses. You verbal queried him and he
    responded. End of story, in my humble opinion. We don't like the answer,
    but it is the answer nonetheless!

    Do you have a physician advisor? The chart needs a second level review
    by a physician who is responsible for quality of care. In the final
    analysis, the infection was sensitive to the antibiotic ordered, and
    that's the most important thing. One case may be an anomaly-maybe he was
    having a bad day. If this is a pattern of behavior, work within your
    medical staff department from a quality perspective as failure to list
    all reportable conditions not only impacts reimbursement, but quality
    reporting as well.


  • tkreilingtkreiling
    Thanks everyone for all the replies. I am leaning towards not querying again as I feel I already did so and even though the answer may not be what I think is right, I am not the physician and he may have had some rationale to why he didn't think it was a UTI.
  • dong.lidong.li
    edited May 2016
    I HAD A PATIENT AND I QUERIED FOR SEPSIS, THERE WERE ENOUGH INDICATORS FOR THIS QUERY. BUT ATTENDING DID NOT ANSWER IT FOR 3 DAYS, FINALLY I SAW HIM IN THE UNIT AND ASKED HIM, HE SAID "I DON'T THINK SO", BUT HE DOCUMENTED SEPSIS IN THE DISCHARGE SUMMERY, MAYBE HE FINALLY GOT SOMETIME TO SIT DOWN AND LOOKED AT ALL THE INDICATORS IN MY QUERY FORM? WHAT I WANT TO SAY IS AMYBE THEY JUST DON'T REALLY HAVE A CLEAR PICTURE YET WHEN WE ASKING THEM AT THAT TIME.


  • robert.hodges2robert.hodges2
    edited May 2016
    The other problem you may have with that is that sepsis only is on the discharge summary and is not documented throughout the stay. It could get interesting if that chart gets audited.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens


  • dong.lidong.li
    edited May 2016
    I know, the problem is we cannot use it as pdx, this attending was too late to het his credit. Sometimes I just don't know what they waiting for.


  • NormaBNormaB
    edited May 2016
    If the clinical indicators are present on admission then you have a case for Sepsis whenever he documents the diagnosis. The definition of Principal Diagnosis is the chief reason the patient was admitted "after study" that caused the patient to be admitted.

    Sometimes you have to wait for test results and cultures to return. If that takes three days before the physician documents the diagnosis it doesn't mean the patient did not have it or you have somehow lost the opportunity for the diagnosis.

    That's when I speak with my physicians about documenting "rule out" or "present on admission". Especially in your discharge summaries.

    But you are right - sometimes you can "jump the gun" or query too early.


  • dallend@einstein.edudallend@einstein.edu
    edited May 2016

    I agree with Robert. Auditors have frequently told us that a diagnosis cannot be in the dc summary alone - it should always be in the body of the chart. A principal dx should always be in both places.
    I would want sepsis documented in the body of the chart as well as the dc summary.
    You could definitely lose this diagnosis in an audit.


  • Unknown
    edited May 2016
    I was told by couple of physicians that even though urine cx has + growth, this
    may be a "chronic bacteuria". If their patients are asymptomatic, they will not
    treat it with abx. So, to them, it is not UTI.

    I guess, even though ER doc, may say it is UTI, their attending physicians
    should have the last word.




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