Health Information Management

Q&A: Coding for a urinary tract infection versus urinary symptoms

JustCoding News: Inpatient, March 17, 2010

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QUESTION: An inpatient develops frequency of urination and burning upon urination on the day of discharge. The physician orders a urine culture and sensitivity and discharges the patient home with PO (i.e., by mouth) antibiotics.

The physician lists urinary tract infection (UTI) as the final diagnosis. For the inpatient record, should I code the UTI or only the urinary symptoms? I’m wondering whether I can code the UTI because it does not appear that the physician treated the UTI prior to discharge. Also the urine culture came back negative. Should I query the physician to determine whether this UTI was ruled out?

ANSWER: The fact that the patient developed the symptoms prior to discharge and went home with antibiotics means that the physician treated this condition prior to discharge. The physician used his medical decision-making skills that resulted in the writing of the prescription for the antibiotics. This counts as treatment, and this occurred while the patient was still in the hospital.

If the physician diagnoses the patient with a UTI but a lab report comes back negative, then you should query the physician referring to both the lab report and notes in which he or she diagnosed the UTI. It is against the law to substitute your opinion for the physician’s determination. However, you may use the documentation and knowledge you have to query for clarification because the two documents in the patient’s chart do not agree.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



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