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.
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:
Example of evidenced-based criteria for residents with an indwelling catheter:
*Both criteria 1 and 2 must be present*
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.”
Contact Richter Healthcare Consultants:
Do you have questions about coding Urinary Tract Infections for MDS 3.0, or other clinical challenges? Call Richter’s clinical education consultants at 866-806-0799 to schedule a free consultation.
Jennifer Leatherbarrow RN, BSN, RAC-CT-QCP, CIC is the Senior Clinical Consultant at Richter Healthcare Consultants. She is a passionate writer and a speaker at both state and national levels. Jennifer has been working in post-acute care for over 20 years. She is an avid proponent of education and providing those on the front lines of healthcare the tools they need to succeed.
Resources for evidence-based UTI criteria:
Loeb criteria:
Surveillance Definitions of Infections in LTC (updated McGeer criteria):
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538836/
National Healthcare Safety Network (NHSN):
https://www.cdc.gov/nhsn/ltc/uti/index.html
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