If a physician documents a cauti not poa, and is seen by infection prevention and the cauti does not meet CDC guidelines thus not reportable to NHSN. Is it still considered a HAC?



  • Coding is driven strictly by MD documentation, and this would be coded as a CAUTI and a HAC unless a compliant ‘validation’ query is initiated with a response from the MD that, after consideration, a CAUTI was not present.  

    Paul Evans, RHIA, 
  • Your Infection Prevention Practitioners will not report it out as such because they are abstracting the record and it doesn't meet criteria. But, Coding and CDI have two choices--1) Code it or 2) Query/clinically validate.

    Once a diagnosis has been entered in the record those are your two choices.

  • Thanks all,
    So as I understand CDI and HIM must know the guidelines for CDC defined cauti., in order to do a "reverse query" to clinically validate.  
    If not reportable to NHSN as a HAI, as it does not meet CDC criteria, is it still considered a HAC ( as doc by the provider) and therefore no additional reimbursement but does not affect star ratings?
     Patient is being tx for a VRE uti not poa 2/2 multiple straight catheterizations. Provider has documented uti 2/2 catheter. Chart coded with a HAC. Infection prevention states no CAUTI.
     So all HAI that are also considered HAC , e.g. CLABS, SSI, must meet CDC clinical definitions to be a valid dx?

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