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Urinary catheter-associated infections: Before or after admission?

From the February ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Richard D. Pinson, FACP

Sidebar: Ask Dr. Pinson

Documentation of urinary catheter-associated infections is very important for correct coding, DRG assignment and regulatory compliance.

Any infection related to a device or catheter of any type is classified for coding purposes as a complication of care. If the infection is the reason for admission, coding rules require the complication code to be sequenced first as the principal diagnosis. Even if the infection progresses to the point of generalized sepsis, the complication code takes precedence.

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Since coders are not permitted to assume any relationship between the presence of a catheter and the infection, the physician must specifically write that the infection is “catheter-related,” or “due to” or “the result of” the catheter (or other similar terminology).

It is essential for the coder to know whether the infection was present at the time of admission. This would be obvious if it were, in fact, the reason for admission. If not documented as present on admission, a urinary catheter-associated infection is designated by CMS as one of twelve “preventable” hospital-acquired conditions (HAC). CMS no longer pays a higher DRG rate based upon HACs as secondary, comorbid diagnoses, and publicly reports on its website every hospital's rate of occurrence for all twelve HACs, including urinary catheter-associated infections.

For this reason, physicians must diligently document any catheter-associated infections that are present at the time the patient is admitted. Fortunately, there is no required time frame during which a physician must identify a condition as present on admission. A brief, explanatory note at any point during the admission will do.

Richard D. Pinson, FACP, is a certified coding specialist and co-founder of HCQ Consulting in Houston. This content is adapted with permission from HCQ Consulting.

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Ask Dr. Pinson

Q: I am wondering about hospital discharge status codes (discharge level of care) that result in a payment reduction. Of the status codes 04, 09, 50 and 51, which (if any) would result in a reduction of payment?

A: CMS's post-acute care transfer (PACT) regulations that may result in reduced DRG payment to the transferring acute care hospital were discussed in the October and November issues. The 2011 PACT rules apply to discharges for 273 specific DRGs from an acute care hospital to any one of six non-acute levels of care. Status codes are assigned to all levels of care for billing purposes.

The six PACT levels of care with status codes are listed below:

• 03–skilled nursing facility (SNF)
• 05–designated cancer center or children's hospital
• 06–home health (within three days of discharge date)
• 62–inpatient rehab facility
• 63–long-term care hospital (LTCH)
• 65–psychiatric hospital

In addition, the reduced reimbursement formula applies to all DRGs when there is a direct transfer from one acute care hospital to another. This type of transfer is not identified by CMS as a post-acute care transfer because the patient remains in “acute care” at both facilities.

CMS has published a summary of these regulations in MLN Matters SE0801. Table 5 of the FY2011 IPPS Final Rule lists all MS-DRGs, relative weights and PACT status.

Got a documentation or coding conundrum? Each month, Dr. Pinson will respond to selected questions from readers. Please e-mail your questions.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated