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.
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.