Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
As we plow through the medical records, there are many factors contributing to Quality Measure misrepresentation. One of the recent findings is the (unfortunate or fortunate depending on how you see it) auto populate function of the diagnoses throughout the record and specifically on the “Face Sheet.”
The facility clinical team must implement a system that provides a check and balance of the patient’s current active diagnoses. Specifically, a review the import feature in the MDS Software and EHR of the ICD 10 of N39.0, Urinary Tract Infection. This diagnosis may pre-populate Section I2300 Urinary Tract Infection, within the past 30-days.
Please make sure to validate the coding of this diagnosis in Section I with the copy forward feature by following the RAI User’s Manual Instructions for coding Item I2300 Urinary tract infection (UTI). The look-back period is 30 days for active disease instead of 7 days.
Code only if all the following are met:
- Physician, nurse practitioner, physician assistant, or clinical nurse specialist or other authorized licensed staff as permitted by state law diagnosis of a UTI in last 30 days.
- Sign or symptom attributed to UTI, which may or may not include but not be limited to:
- urinary symptoms (e.g., peri-urethral site burning sensation,
- frequent urination of small amounts),
- pain or tenderness in flank,
- confusion or change in mental status,
- change in character of urine (e.g., pyuria).
- “Significant laboratory findings” (The attending physician should determine the level of significant laboratory findings and whether or not a culture should be obtained).
- Current medication or treatment for a UTI in the last 30 days.
Harmony Healthcare International (HHI) hopes these tips are beneficial to you and your facility staff. We understand that the amount of information and changes can be overwhelming. Our intent is to “distill and synthesize” the volume of information and ultimately save you time. And then, you can get back to the reason you went into business in the first place…to give great care to the senior population.
Need additional training or a better understanding of Quality Measures, especially in regards to pain? Join us for our upcoming MDS Competency Courses (CHHi-MDS). Click here to see the dates and locations.
6th Annual LTPAC Symposium
Click Here to Register