Skip to main content Accessibility help
×
Home

Hospital-Acquired Catheter-Associated Urinary Tract Infection: Documentation and Coding Issues May Reduce Financial Impact of Medicare's New Payment Policy

  • Jennifer Meddings (a1), Sanjay Saint (a1) (a2) and Laurence F. McMahon (a1)

Extract

Objective.

To evaluate whether hospital-acquired catheter-associated urinary tract infections (CA-UTIs) are accurately documented in discharge records with the use of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes so that nonpayment is triggered, as mandated by the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Conditions Initiative.

Methods.

We conducted a retrospective medical record review of 80 randomly selected adult discharges from May 2006 through September 2007 from the University of Michigan Health System (UMHS) with secondary-diagnosis urinary tract infections (UTIs). One physician-abstractor reviewed each record to categorize UTIs as catheter associated and/or hospital acquired; these results (considered “gold standard”) were compared with diagnosis codes assigned by hospital coders. Annual use of the catheter association code (996.64) by UMHS coders was compared with state and US rates by using Healthcare Cost and Utilization Project data.

Results.

Patient mean age was 58 years; 56 (70%) were women; median length of hospital stay was 6 days; 50 patients (62%) used urinary catheters during hospitalization. Hospital coders had listed 20 secondary-diagnosis UTIs (25%) as hospital acquired, whereas physician-abstractors indicated that 37 (46%) were hospital acquired. Hospital coders had identified no CA-UTIs (code 996.64 was never used), whereas physician-abstractors identified 36 CA-UTIs (45%; 28 hospital acquired and 8 present on admission). Catheter use often was evident only from nursing notes, which, unlike physician notes, cannot be used by coders to assign discharge codes. State and US annual rates of 996.64 coding (~1% of secondary-diagnosis UTIs) were similar to those at UMHS.

Conclusions.

Hospital coders rarely use the catheter association code needed to identify CA-UTI among secondary-diagnosis UTIs. Coders often listed a UTI as present on admission, although the medical record indicated that it was hospital acquired. Because coding of hospital-acquired CA-UTI seems to be fraught with error, nonpayment according to CMS policy may not reliably occur.

Copyright

Corresponding author

300 North Ingalls Building, Room 7D-10, Ann Arbor, Michigan 48109, (meddings@umich.edu)

References

Hide All
1.Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2008 rates. Federal Regist 2007;72(162): 4712948175.
2.Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates. Federal Regist 2008;73(161): 4847348491.
3.Phipps, S, Lim, YN, McClinton, S, Barry, C, Rane, A, N'Dow, J. Short term urinary catheter policies following urogenital surgery in adults. Cochrane Database Syst Rev 2006(2):CD004374.
4.Niel-Weise, BS, van den Broek, PJ. Urinary catheter policies for short-term bladder drainage in adults. Cochrane Database Syst Rev 2005(3): CD004203.
5.Jain, P, Parada, JP, David, A, Smith, LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med 1995; 155(13):14251429.
6.Fernandez, R, Griffiths, R. Removal of short-term indwelling urethral catheters. Joanna Briggs Inst Best Pratt Tech Rep 2006;2(3):132.
7.Dunn, S, Pretty, L, Reid, H, Evans, D. Management of short term indwelling urethral catheters to prevent urinary tract infections: a systematic review. Joanna Briggs Inst 2000;6:164.
8.Wong, ES. Guideline for prevention of catheter-associated urinary tract infections. Am J Infect Control 1983;11(1:2836.
9.Warren, JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am 1997;11(3):609622.
10.Stamm, WE. Catheter-associated urinary tract infections: epidemiology, pathogenesis, and prevention. Am J Med 1991;91(3B):65S71S.
11.Smith, JM. Indwelling catheter management: from habit-based to evidence-based practice. Ostomy Wound Manage 2003;49(12:3445.
12.Yokoe, DS, Mermel, LA, Anderson, DJ, et al.A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(suppl 1):S12S21.
13.Lo, E, NicoUe, L, Classen, D, et al.Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(suppl 1):S41S50.
14.Gould, CV, Umscheid, CA, Agarwal, RK, Kuntz, G, Pegues, D; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections 2009. Centers for Disease Control and Prevention Web site, http://www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html. Published 2008. Accessed November 10, 2009.
15.Foxman, B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Am J Med 2002;113(suppl 1A):5S13S.
16.Saint, S, Wiese, J, Amory, JK, et al.Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med 2000;109(6:476480.
17.Fakih, MG, Dueweke, C, Meisner, S, et al.Effect of nurse-led multidis-ciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients. Infect Control Hosp Epidemiol 2008;29(9): 815819.
18.Saint, S, Meddings, JA, Calfee, D, Kowalski, CP, Krein, SL. Catheter-associated urinary tract infection and the Medicare rule changes. Ann Intern Med 2009;150(12:877884.
19.Coffey, R, Milenkovic, M, Andrews, R. The case for the present-on-admission (POA) indicator. Healthcare Cost and Utilization Project Web site, http://www.hcup-us.ahrq.gov/reports/methods.jsp. Published 2006. Accessed June 1, 2008.
20.Present on admission (POA) indicator reporting by acute inpatient prospective payment system (IPPS) hospitals. Centers for Medicare and Medicaid Services Web site. http://www.cms.hhs.gov/HospitalAcqCond/Downloads/POAFactsheet.pdf. Published October 2008. Accessed November 10, 2009.
21.Horan, TC, Andrus, M, Dudeck, MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36(5:309332.
22.Catheter-associated urinary tract infection (CAUTI) event. In: CDC Division of Healthcare Quality Promotion, ed. The National Healthcare Safety Network (NHSN) Manual. http://www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf. Published 2009. Accessed April 25, 2010.
23.Jarvis, WR. Benchmarking for prevention: the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance (NNIS) system experience. Infection 2003;31(suppl 2):4448.
24.Braunwald, E, Fauci, A, Kaspar, D, Hauser, S, Longo, D, Jameson, J, eds. Harrison's Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill; 2001.
25.Hooton, TM. Urinary tract infection. In: Wachter, RM, Goldman, L, Hollander, H, eds. Hospital Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2005.
26.McPhee, SJ, Papadakis, MA, eds. Current Medical Diagnosis and Treatment. 48th ed. New York, NY: McGraw-Hill/Lange, 2009.
27.Passaretti, A, Ardehali, H, Nuermberger, E. Urinary tract infections. In: Nilsson, KR, Piccini, JP, eds. The Osier Medical Handbook. 2nd ed. Philadelphia, PA: Saunders Elsevier, 2006.
28. Centers for Medicare and Medicaid Services; National Center for Health Statistics. ICD-9-CM official guidelines for coding and reporting. Effective October 1, 2009. National Center for Health Statistics Web site. http://www.cdc.gov/nchs/data/icd9/icdguide09.pdf. Published August 31, 2009. Accessed November 10, 2009.
29.Maki, DG, Tambyah, PA. Engineering out the risk for infection with urinary catheters. Emerg Infect Dis 2001;7(2):342347.
30.Wagenlehner, FM, Naber, KG. Hospital-acquired urinary tract infections. J Hosp Infect 2000;46(3):171181.
31.Healthcare Cost and Utilization Project (HCUPnet). Agency for Healthcare Research and Quality Web site, http://hcupnet.ahrq.gov/. Accessed August 4, 2009.
32.Zhan, D, Elixhauser, A, Richards, CL, et al.Identification of hospital-acquired catheter-associated urinary tract infections from Medicare claims: sensitivity and positive predictive value. Medical Care 2009;47(3:364369.

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed