Harmony Healthcare Blog

The MDS Coding Corner: Urinary Tract Infections (UTIs)

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Tue, Feb 21, 2017

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Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

nursedocumentation.jpgClinical Considerations for Urinary Tract Infection (Long Stay Quality Measure) includes the process of coding an Active UTI within the last 30 Days of the MDS Section I: Active Medical Conditions. 

If your facility is seeing an upward trend in the reporting of active UTI,  The Harmony Healthcare Team recommends further investigation and a deep dive of the Quality Measure UTI Triggers. Harmony Healthcare International (HHI) suggests initiating a QAPI focused strategy with the implementation of a Performance Improvement Plan to evaluate MDS Coding in relation to UTI.  This would include an audit of the below clinical considerations and application to a designated sample size. 

Clinical Considerations for UTI 

  1. MDS Coding of a UTI has to meet all of the below clinical criteria:
    • Diagnosis of UTI in the last 30 days.
    • Sign or symptom attributable to a UTI.
    • “Significant Laboratory Findings” in the record.
    • Current medication or treatment for UTI in the last 30 days.
  2. Validate that only those infections which meet the above criteria are coded on the MDS.
    • Note: The McGeers and Loeb criteria are often used as the definitive authority on the presence of a UTI and whether or not to treat with antibiotics. 
    • That is a separate issue from whether or not to code UTI on the MDS.
    • If they did not meet McGeers or Loeb’s criteria, they probably would not have been on a medication, and therefore could not be coded for UTI in I2300.
  3. All technicalities aside, Care Plan for any condition that is a problem or concern.  Diagnosis or not. 
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Quality Measure Parameters for UTI 

Coding will meet the criteria of UTI Long Stay Quality Measure for Percentage of Residents with a Urinary Tract Infection if the following items are coded on the MDS:

  1. MDS Coding Items:
    • Item I2300.
    • Long-stay residents with a selected target assessment that indicates a UTI in the last 30 days. 
  2. Risk Adjustments:
    • Exclusion:  Target assessment is an OBRA Admission Assessment or a PPS 5 Day Assessment.
    • UTI is dash filled

Harmony Healthcare International (HHI) is available to provide ongoing education and training on MDS Accuracy and Clinical Considerations for Urinary Tract Infections.   

If you need assistance with the MDS Coding of UTIs, please contact us by clicking here or calling our office at (800) 530-4413. 

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Tags: Urinary Tract Infections

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