Inpatient Facility Coding & Compliance Alert

Question: An 8-year-old female was admitted with general weakness. She said her Foley catheter was changed recently, but couldn't remember exactly when. She mentioned she has had other urinary tract infections (UTIs), but documentation in the medical record doesn't confirm that the UTI was due to the catheter. Other documentation noted a history of hypertension and neurogenic bladder with a chronic indwelling Foley catheter. How should we classify this case?

Answer: Before you can connect the UTI with the Foley catheter, the physician must link the infection to the device. You don't have that support in the medical record, or in his note about the bladder problem "with" an indwelling catheter (the term "with" doesn't establish a cause and effect relationship, or indicate the urinary catheter caused the UTI). Your description of the situation also doesn't note whether the physician was asked about the cause of the UTI.

Considering these factors, your best choice for principal diagnosis is 599.0 (Urinary tract infection; site not specified). That leads you to an assignment of MS-DRG 690 (Kidney and urinary tract infections without MCC).