Q&A: Linking relationship of Foley catheter with UTI
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Q: A few days into the patient’s stay an order for a Foley catheter was placed for incontinence and around the same time the physician documented a urinary tract infection (UTI). Would it be appropriate to query the physician regarding the relationship of the UTI to the Foley? Our infection control department caught this but we did not.
I am concerned about this for two reasons; first, I worry about writing a leading query and second, whether the UTI could be considered a hospital acquired condition (HAC) if additional documentation isn’t provided.
A: You raise an important concern, with this question, something which those on the cutting edge of collaboration between coding/CDI and infection control have been ruminating about of late.
In the coming years, I think CMS will begin auditing the discrepancies among coded data and reported surveillance data for things like Catheter-Associated Urinary Tract Infection (CAUTI) and Central Line-Associated Bloodstream Infection (CLABSI). As these conditions become part of hospital value based purchasing (HVBP) it will indirectly impact reimbursement even more than if they are simply identified as a HAC.
It would not be leading to ask the provider for clarification if there is a relationship as you would want the coding to accurately reflect the patient’s condition. You might write a query as follows:
Dear Dr. Foley:
The diagnosis of UTI appears (where/when). Ms. X (the patient’s name) had an order for a Foley catheter (when) that was placed by nursing staff. Could you please clarify in the next progress note (or however your providers respond) what, if any, relationship exists between the UTI and the Foley catheter.
- There is no relationship between the Foley catheter placed on ___(you add in the date when the Foley was placed) and the UTI
- There is evidence the UTI is associated with the Foley catheter
- Unable to determine
- Other: ____________
I used the phrase “evidence of” the UTI associated with the Foley because the provider may not be able to determine beyond a shadow of a doubt so this gives the provider wiggle room while allowing accurate coding if there is a relationship.
Editor’s Note: See also Q&A: Identifying etiology/manifestation vs. complication connections.
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Amy Packwood CCS | Mar 18, 2014 | Reply
Our biggest problem has been a high number of patients admitted with a uti and foley already in place. When is it appropriate to code from the 900 codes as principal? or even a secondary with the poa being y. I feel we are over querying about the foley relation .We have at least one a day. I think the physicians are getting irritated.
TJ Williams, RN, BS, CDIP | Mar 19, 2014 | Reply
If the patient presents to the hospital with pyuria with an Indwelling catheter, physicians request that a culture be sent, and that the foley be replaced. That very action suggests that the UTI is suspected to be secondary to the catheter, and if they do not connect the dots, a query must be generated. This situation represents a complicated UTI, and the complication code should be assigned. These patients usually are from a SNF and are given the dreaded “urosepsis” diagnosis, as they are often also dehydrated and altered. If we do not establish that the culprit catheter is POA, then it becomes a HAC, which penalizes the hospital.
Amy Stremming, RN | Mar 22, 2014 | Reply
If documentation is clear that the indwelling foley was in place upon admission, and the urine collected for urinalysis/culture was obtained upon admission, is that sufficient documentation to avoid a HAC?
In our facility, the doctors usually respond that they are unsure of a link; your ‘evidence of’ suggestion just might work.
TJ Williams, RN, BS, CDIP | Mar 22, 2014 | Reply
Amy, utilize any documentation by nursing to further support that the UTI was present while the old catheter was in place. The date and time of collection according to lab results and the date that the new catheter was inserted are great supportive clinical indicators. If a culture results “positive” collected at the same time a new catheter is inserted, this will make the physician’s response in agreement to the link a “no brainer”….hopefully!