Encounter code for UTI due to catheter
I don't usually ask coding questions here because this is not a coding forum, but this question came from my team today and I haven't been able to find a definitive answer:
A patient is admitted with a UTI due to self-catheterization. There's nothing in her current record about old UTIs, but reviewing old records shows she's been admitted repeatedly for the same problem. It would be impossible to tell if she was "cured" of the previous UTIs as no interim cultures were done, so would you consider this a new problem each time or a continuation of the old problem? Would you report this as an initial encounter or a subsequent encounter? What about recurrent CAUTIs when the Foley's been previously changed? Thx.
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System
A patient is admitted with a UTI due to self-catheterization. There's nothing in her current record about old UTIs, but reviewing old records shows she's been admitted repeatedly for the same problem. It would be impossible to tell if she was "cured" of the previous UTIs as no interim cultures were done, so would you consider this a new problem each time or a continuation of the old problem? Would you report this as an initial encounter or a subsequent encounter? What about recurrent CAUTIs when the Foley's been previously changed? Thx.
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System
Comments
[cid:image001.png@01D0FF50.17C61B30]
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org