UTI?

bbogda@morrishospital.org

Denial received on this patient with documentation of Uti, urine culture results below.  Payer states that 10,000 colonies in a culture does not support diagnosis of UTI.  They are also saying the usual about no complaints of urinary symptoms (92 y/o with dementia).
Fair or appeal?

 

URINE CULTURE  Final  

        OBSERVATIONS:   10,000 CFU/ML  GRAM NEGATIVE BACILLI

     Organism 1                     ENTEROBACTER CLOACAE

                                    SUSCEPTIBILITY TO FOLLOW

     1. ENTEROBACTER CLOACAE

                                    M.I.C.    RX  Target Route Dose                      

                                    --------- --- ------ ----- ------------------------- 

     TRIMETHOPRIM/SULFAMETHOXAZOLE  <=2/38     S                                         

     AMPICILLIN                     >16        R                                         

     AMPICILLIN/SULBACTAM           16/8      R*                                         

     AZTREONAM                      <=4        S                                         

     CEFAZOLIN                      >16        R                                         

     CEFOTAXIME                     <=2        S                                         

     CEFOXITIN                      >16        R                                         

     CEFTAZIDIME                    <=1        S                                         

     CEFTRIAXONE                    <=1        S                                         

     CEFEPIME                       <=4        S                                         

     CEFUROXIME                     8         R*                                         

     CIPROFLOXACIN                  <=1        S                                         

     LEVOFLOXACIN                   <=2        S                                         

     GENTAMICIN                     <=4        S                                         

     IMIPENEM                       <=1        S                                         

     ERTAPENEM                      <=1        S                                         

     MEROPENEM                      <=1        S                                         

     NITROFURANTOIN                 >64        R                                         

     TOBRAMYCIN                     <=4        S                                         

     AMIKACIN                       <=16       S                                         

     PIPERACILLIN/TAZOBACTAM        <=16       S     

lprescott1

the old measure was 100,000 CFU/Ml- but i know there is research that lower numbers can indeed confirm the diagnosis of UTI. I would want to see documentations of symptoms and treatment. if you have no symptoms, and no treatment I don't think it is worth the appeal.

bbogda@morrishospital.org

The doctor documented the urinary tract infection and treated her for it.  I have a hard time with 'symptoms' because we get so many elderly patients from the nursing homes with no urinary symptoms.  They usually are altered to begin with due to dementia, but may present because they are more altered than usual, or had a fall, or some other complaint.  Some of them couldn't tell you if they had burning or pain even if they did.  They may not even have a fever, but when investigating a cause for presenting symptoms, a urine culture will grow out positive.

In this case, the payer is not only denying due to lack of symptoms in this elderly demented female, but because the culture did not yield the right amount of colonies.  Our docs are trying to give the best care according to their professional opinions, but get denied reimbursement because their patients aren't textbook examples. Frustrating. 

kshumpert

I have had the same denials. If I can find any evidence of an altered mental state, even at baseline, I argue that the review of systems may not be accurate due to the dementia-that will cover the reviewer's implication of absent or negative ROS. I include references that discuss the difference in clinical presentation of the elderly patient.  Remember, that elderly patient, especially the demented, can often present with an atypical presentation such as increase confusion or falls.  I would imagine that the nursing home sent the patient due to an alteration in the patient's baseline-use this as an atypical symptom.  One article I use is from UpToDate, Immune Function in Older Adults by Antoine Azar, MD

Zuhair K Ballas, MD. 

bbogda@morrishospital.org

Thank you Kshumpert, this is helpful.

ebraun

I just had one of these come across my desk right now.  I will use that up to date reference.  Thank you!  It's very frustrating to say the least! 

kshumpert said:

I have had the same denials. If I can find any evidence of an altered mental state, even at baseline, I argue that the review of systems may not be accurate due to the dementia-that will cover the reviewer's implication of absent or negative ROS. I include references that discuss the difference in clinical presentation of the elderly patient.  Remember, that elderly patient, especially the demented, can often present with an atypical presentation such as increase confusion or falls.  I would imagine that the nursing home sent the patient due to an alteration in the patient's baseline-use this as an atypical symptom.  One article I use is from UpToDate, Immune Function in Older Adults by Antoine Azar, MD

Zuhair K Ballas, MD. 

vparent@emhs.org

I also feel treatment must be documented and would respond back what antibiotic they received an for how long as well as mentioned previously if there is a history of dementia, subjective patient assessment  is not always reliable. Particular in dementia patients, their behavior has changed enough to make family/or caregivers question what is wrong.