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Ask the expert: POA for UTI

HIM Connection, April 15, 2008

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Question: A physician admits a patient who already has a urinary catheter in place. After admitting the patient, the nurse changes the patient's existing urinary catheter and inserts a new one. On day two of the admission, the patient's temperature spikes to 101ºF. The physician obtains a culture from the tip of the catheter and identifies that E-coli bacteria is present. The physician documents that the patient has an E-coli urinary tract infection (UTI) due to the catheter. Is it appropriate to query the physician regarding whether the UTI was present on admission (POA), or can you simply report a POA indicator based on the documentation? If you can report an indicator, which one should you report?

Answer: You must query the physician. The documentation is insufficient as to whether the condition was POA. In the above scenario, the question that the physician may or may not be able to answer is whether the infection already existed with the existing catheter, or whether it developed subsequent to the insertion of the new catheter on admission. You may end up reporting a W indicator to indicate that it is clinically undetermined as to whether the condition was POA. Because the physician did not obtain a culture to verify that an infection did not exist from the original catheter prior to inserting a new one, you can likely consider it clinically undetermined.

Editor's note: Shannon E. McCall, RHIA, CCS, CPC, director of coding and HIM for HCPro, Inc., in Glen Allen, VA, answered this question. This Q&A appeared in the April issue of Medical Records Briefing. For more information, visit www.hcpro.com/content/207193.cfm.

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