Long-Term Care Survey Alert

Published on Thu May 21, 2009 PDF

Is your facility up to speed on the latest RAIUser's Manual update for coding UTIs? For purposes of coding UTI in Section I2, the resident has to have significant lab findings to support the diagnosis of a symptomatic UTI. And people in most cases interpreted "significant lab findings" to be a positive urine culture and sensitivity, says Ron Orth, RN, NHA,CPC, RAC-MT, president of Clinical Reimbursement Solutions LLC in Milwaukee. But with the recent RAI Manual update, CMS is allowing the attending physician to determine the level of significant lab findings and whether to do a urine culture. Thus,the "lab finding could be a urinalysis or some other type of lab test -- a CBC, for example -- in order to make that affirmative diagnosis,"Orth says. "The MDS still says you code symptomatic UTIs,"such as a mental status change, urinary frequency,urgency, flank pain,etc., Orth says.

Important: Make sure the physicians provide some documented rationale in the clinical record as to the laboratory findings and whether a culture is warranted and supports a diagnosis of UTI,advises Jane Belt, MS,RN, managing consultant with Plante & Moran Clinical Group in Columbus, Ohio. The facility could obtain an explanatory statement as part of a telephone order, suggests Marilyn Mines, RN, RAC-CT,BC, manager of clinical services for FR&R Healthcare Consulting in Deerfield, Ill. As an example, the statement might read: "Keflex 500 mg tid for 10 days for symptomatic UTI (concentrated,odorous urine) with abnormal U/A lab results."