Last year brought some significant changes in the way we code a urinary tract infection (UTI) in Section I of the MDS. When you are determining whether to code a UTI, at first glance, it seems pretty straightforward. However there are multiple factors included in the determination of coding. 

• The first thing you need to determine is whether the resident has had a UTI in the last 30 days. Section I has a lookback of seven days, but the UTI is a full 30 days. There are now only two criteria that must be met once you have found a UTI in the 30-day lookback. Remember, the 30-day lookback is calculated from the assessment reference date (ARD) of the assessment.
• Code the UTI only if BOTH of the following are met in the last 30 days:
  • The resident had a UTI using evidence-based criteria such as McGeer, NHSN or Loeb in the last 30 days
  • A physician-documented UTI diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days

To properly code, the facility must use evidence-based criteria, and such criteria should be maintained in the resident record.

Example of evidenced-based criteria for residents without an indwelling catheter:

• At least one of the following signs or symptoms:
  • Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis or prostate
  • Fever or leukocytosis (see Table 2) and at least one of the following localizing urinary tract sub-criteria:
    • Acute costovertebral angle pain or tenderness
    • Suprapubic pain
    • Gross hematuria
    • New or marked increase in incontinence
    • New or marked increase in urgency
    • New or marked increase in frequency
  • In the absence of fever or leukocytosis, then two or more of the following localizing urinary tract sub-criteria:
    • Suprapubic pain
    • Gross hematuria
    • New or marked increase in incontinence
    • New or marked increase in urgency
    • New or marked increase in frequency
• One of the following microbiologic sub-criteria:
  • Urine specimens for culture should be processed as soon as possible, preferably within 1–2 hours. If urine specimens cannot be processed within 30 minutes of collection, they should be refrigerated. Refrigerated specimens should be cultured within 24 hours.
  • At least 105 CFU/mL of no more than two species of microorganisms in a voided urine sample
  • At least 102 CFU/mL of any number of organisms in a specimen collected by in-and-out catheter

Example of evidenced-based criteria for residents with an indwelling catheter:

*Both criteria 1 and 2 must be present*

• At least one of the following signs or symptoms:
  • Fever, rigors or new-onset hypotension, with no alternate site of infection
  • Either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis
  • New-onset suprapubic pain or costovertebral angle pain or tenderness
  • Purulent discharge from around the catheter or acute pain, swelling or tenderness of the testes, epididymis or prostate
• Urinary catheter specimen culture with at least 105 CFU/mL of any organism(s)
  • Urinary catheter specimens for culture should be collected following replacement of the catheter (if current catheter has been in place for >14 days)

The issue of “colonization” is always brought up when UTI’s are discussed, so the Resident Assessment Manual (RAI) has also added the following passage:

“A physician often prescribes empiric antimicrobial therapy for a suspected infection after a culture is obtained, but prior to receiving the culture results. The confirmed diagnosis of UTI will depend on the culture results and other clinical assessment to determine appropriateness and continuation of antimicrobial therapy. This should not be any different, even if the resident is known to be colonized with an antibiotic resistant organism. An appropriate culture will help to ensure the diagnosis of infection is correct, and the appropriate antimicrobial is prescribed to treat the infection. The CDC does not recommend routine antimicrobial treatment for the purposes of attempting to eradicate colonization of MRSA or any other antimicrobial resistant organism.”