To Link or Not to Link?

sbourque

MD documents complicated UTI.  He documents in the progress notes "U/A + bacteria + yeast".  MD never links the UTI to the organisms noted in the the progress notes.

the coder coded as B3749 other urogenital candidiasis

CDI coded as n390 UTI unspecified

Does the UTI have to be linked to an organism in the MD documentation for it be coded as other urogenital candidiasis?

evanspx@sutterhealth.org

Yes..the record must clearly document the infective organism and simply mentioning a positive culture is not adequate.  

P. Evans, RHIA, CCDS