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Q: What type of documentation do I need to look for when coding a urinary tract infection (UTI) in item I2j of the MDS? Does just the presence of an antibiotic count?

Julia's PPS Chat, October 26, 2005

Welcome once again to our PPS chat!

Coding items accurately on the MDS is very important. You'll want to be sure that your documentation matches your assessment of the resident.

Read on to find out how to code urinary tract infections-

Q: What type of documentation do I need to look for when coding a urinary tract infection (UTI) in item I2j of the MDS? Does just the presence of an antibiotic count?

A: The revised Resident Assessment Instrument (RAI) User's Manual clarifies when to code a UTI.

Page 3-136 defines a UTI as including, "chronic and acute symptomatic infection(s) in the last 30 days. Check this item only if there is current supporting documentation and significant laboratory findings in the clinical record. For a new UTI condition identified during the observation period, a physician's working diagnosis of UTI provides sufficient documentation to code the UTI at item I2j, as long as the urine culture has been done and your are waiting for results."

First, assess for a UTI using a 30-day lookback period. Check item I2j only if the UTI was present during this time period. Then, be sure that you have the required supporting documentation as identified in the RAI User's Manual definition.

The presence of only an antibiotic with no additional documentation or lab results would not be sufficient for coding a UTI. Also, if you code a UTI based on significant laboratory findings but later determine the UTI was not present, you must complete a corrected MDS to remove the diagnosis.

Be sure to follow this definition closely. You'll want to assess the resident, review the medical record documentation, and talk with staff members and the resident. Then you should have the best picture as to what is going on with the resident and your coding should reflect that accuracy.

We'll be chatting again soon-