UTI Definition Workgroup
Purpose
• To develop standard clinical definitions on select
diagnoses & categories to be used consistently across
all hospitals in Maryland


Definitions will be informed by published criteria, existing hospitaldeveloped definitions and supported by industry consensus and
comments from the field
Definitions will not conflict with federal inpatient coding guidelines and
will be applied to any occurrence of the diagnosis, not only in scenarios
that might trigger a PPC
• Our goal is that these definitions will be considered and
adopted by hospitals’ Medical Executive Committees
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Background
• Under the state’s waiver agreement, hospitals must meet reduction
targets for Potentially Preventable Complications (PPCs)
 Additionally, the Health Services Cost Review Commission
(HSCRC) incorporates reduction targets into payment policy
• Having a uniform set of clinically defining criteria may facilitate care
improvement
 Consistency allows for both a performance comparison amongst
hospitals and for a measurement of an individual hospital’s
performance improvement over time
 Consistency helps demonstrate that Maryland hospitals have
put in time and effort to achieve clinically significant
performance improvement in addition to improvement achieved
through revised documentation practices
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Participants
HOSPITALS
Adventist Healthcare
Brian Carpenter, MD, Chief Hospitalist, Adventist HealthCare Shady Grove Medical Center
Michelle Cousineau, Senior Coding Coordinator, Adventist HealthCare
Joy Gill, Clinical Data Manager, Adventist HealthCare
Johns Hopkins
Julia Gardner, Infection Control Epidemiologist, Johns Hopkins Hospital
Kerri Huber, Infection Prevention Manager, Johns Hopkins Bayview Medical Center
Heidi Milby, Coding Compliance Auditor, Johns Hopkins Hospital
Pat Rodriguez, Coding Quality Manager, Johns Hopkins Health System
Julie Trivedi, MD, Clinical Associate In Medicine, Department Of Medicine, Division Of Infectious Diseases At Johns Hopkins
Lifebridge Health
Mary Lou Bond, Data Quality Manager, Lifebridge Health
Rose Lim, Clinical Documentation Improvement Specialist, Lifebridge Health
Medstar Health
Bernard Ravitz, MD, Physician Advisor PAC-CDI, Medical Director for SSU/Observation Unit, MedStar Good Samaritan
University of Maryland
Mangla Gulati, MD, Medical Director For Clinical Effectiveness, UMMC
Surbhi Leekha, Assistant Professor for Epidemiology and Public Health, UMMC
Michael Anne Preas RN, Director Infection Prevention and Control, UMMC
STAFF
Maryland Hospital Association
Nicole Stallings, Vice President
Justin Ziombra RN, Analyst
Berkeley Research Group
Joni Dion, Associate Director
Kristen Geissler, Managing Director
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Phase 1 Meeting Calendar
January 13
UTI
PPCs 65, 66
January 28
February 17
January 20
Renal
PPCs 24, 25
February 2
February 23
January 29
OB
PPCs 55, 56, 57, 58
February 18
March 5
February 5
Respiratory
PPCs 3, 4, 5, 6
February 19
March 10
All meetings to be held from 8:30 – 11:30 at MHA
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Meeting Workflow Schedule
•
•
•
•
•
Meeting 1, January 20:
 Review coding rules, query rules and how clinical definitions can and cannot be
used
 Review existing definitions to eliminate non-starters, identify similarities and
develop an initial consensus
Homework prior to Meeting 2:
 Participants will review initial consensus with appropriate clinical and
administrative stakeholders for input
Meeting 2, January 28:
 Review feedback from stakeholders and update draft definitions
Homework prior to Meeting 3:
 Draft definitions will be submitted to hospital field for comment
Meeting 3, February 17:
 Review comments
 Finalize definitions
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Coding Guidelines
Documentation for Coding Purposes
•
ICD-9-CM Official Guidelines for Coding and Reporting have been approved by the four
cooperating parties:
 The American Hospital Association (AHA)
 The American Health Information Management Association (AHIMA)
 The Centers for Medicare and Medicaid Services (CMS)
 The National Center for Health Statistics (NCHS)
•
The inpatient coding process is based on the documentation provided by licensed
providers who are treating the patient
 Generally, the provider treating the patient will be the “attending physician”
− The use of attending physician documentation is the “gold standard,” however,
sometimes it may not be practical or optimal to only accept documentation from
the attending physician
EXAMPLE
The consultant documents UTI, but the attending physician does not; If there is no conflicting
documentation the UTI would be coded; If there is conflicting documentation, then the
attending physician would be queried for clarification
References:
1. AHIMA Standards of Ethical Coding
2. Coding Clinic – 3Q/2006, Page 10
3. Centers for Medicare and Medicaid Services
4. Federal Register 42 cfr 412.46
5. ICD-9-CM Official Guidelines for Coding and Reporting
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Guidelines for Coding and Reporting
ICD-9-CM Official Guidelines for Coding and Reporting
•
Selection of Principal Diagnosis
 The principal diagnosis is “the condition established after study to be chiefly
responsible for occasioning the admission of the patient to the hospital for care”
•
General Rules for Other (Additional) Diagnoses
 For reporting purposes the definition for “other diagnoses” is interpreted as
additional conditions that affect patient care in terms of requiring:
− clinical evaluation; or
− therapeutic treatment; or
− diagnostic procedures; or
− extended length of hospital stay; or
− increased nursing care and/or monitoring
•
Each case has one principal diagnosis, and in Maryland, up to 29 reportable
additional conditions
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Guidelines for Coding and Reporting
ICD-9-CM Official Guidelines for Coding and Reporting
•
Abnormal findings
 Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are
not coded and reported unless the provider indicates their clinical significance
− If the findings are outside the normal range and the attending provider has
ordered other tests to evaluate the condition or prescribed treatment, then
it is appropriate to ask the provider whether the abnormal findings should
be added
•
Uncertain Diagnosis
 If the diagnosis documented at the time of discharge is qualified as “probable,”
“suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out” or other
similar terms indicating uncertainty, then code the condition as if it existed or
was established
 Note: This guideline is applicable only to inpatient billing (not to physician billing)
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Coding Clinic
•
Catheter-Associated Urinary Tract Infection (CAUTI)
 If there is no provider documentation of a Catheter-Associated Urinary Tract
Infection (CAUTI), but there is documentation that the patient has a Urinary
Tract Infection (UTI) and it is noted that the patient has an indewelling catheter,
then the coder cannot assume a relationship; The provider must clearly
document the causal relationship (UTI secondary to or due to indewelling
catheter)
−
−
•
Coding Clinic, Third Quarter 2009, Pages 10 – 11
Coding Clinic, Second Quarter 2012, Pages 20 – 21
UROSEPSIS
 Urosepsis is an infection, which started in the urinary system; The term
urosepsis refers to pyuria or bacteria in the urine (not the blood) and is coded to
UTI
 If the condition has progressed to a septicemia in which a localized UTI has
entered the blood stream, the physician should be queried for clarification to
capture accurate codes to reflect the illness of the patient
−
−
Coding Clinic, First Quarter 1998, Page 5
Coding Clinic, Second Quarter 2000, Page 6
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Clinical Definitions
•
Clinical Definitions:



Can provide guidance to coding professionals and/or clinical documentation
specialist on when to query the providers
Should not replace a query to determine the appropriate code
− For example, if a UTI is documented but does not have appropriate clinical
indicators per the definitions a query should be generated to confirm the
diagnosis
Clinical definitions are recommended to be formally approved by hospital
medical staff
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UTI Related ICD-9-CM Codes
Documented Diagnosis
ICD-9 Diagnosis
Description
Urinary Tract Infection
Urinary Tract Infection,
599.0
Site Not Specified
Asymptomatic Urinary Tract
Infection
Urinary Tract Infection,
599.0
Site Not Specified
Catheter Associated Urinary
Tract Infection
Urinary Complication; 997.5
Urinary Tract Infection 599.0
Bacteriuria
Nonspecific Findings
on Examination of
Urine
791.9
Pyuria
Nonspecific Findings
on Examination of
Urine
791.9
Chronic Urinary Tract Infection
w/o Symptoms on Long Term
Antibiotics
Long Term (current)
Use of Antibiotics
V58.62
ICD-9-CM Code
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UTI Related ICD-10-CM Codes
Documented Diagnosis
ICD-10 Diagnosis
Description
Urinary Tract Infection
Urinary Tract Infection,
N390
Site Not Specified
Asymptomatic Urinary Tract
Infection
Urinary Tract Infection,
N390
Site Not Specified
Catheter Associated Urinary
Tract Infection
Infection &
Inflammatory Reaction
Due to Indwelling;
T8351XA
Urinary Catheter
N390
Urinary Tract Infection,
Site Not Specified
Bacteriuria
Urinary Tract Infection,
N390
Site Not Specified
Pyuria
Urinary Tract Infection,
N390
Site Not Specified
Chronic Urinary Tract Infection
Urinary Tract Infection,
N390
Site Not Specified
ICD-10-CM Code
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Currently Used Definitions
CDC / NHSN Criteria
•
To meet CDC / NHSN’s criterion for a UTI, the patient must meet both of the following criteria:
Patient has at least one of the following signs or symptoms:
•
•
•
•
•
•
Fever >38.0°C (in a patient that is ≤ 65 years of age if a catheter is not in place)1
Suprapubic tenderness with no other recognized cause
Costovertebral angle pain or tenderness with no other recognized cause
Urinary frequency with no other recognized cause2
Urinary urgency with no other recognized cause2
Dysuria with no other recognized cause2
AND
Patient has a urine culture with no more than two species of organisms, at least
one of which is a bacteria of ≥105 Colony-Forming Unit (CFU)/ml
Difference between a catheter and non-catheter related UTI:
A UTI is catheter-associated (CAUTI) if the indwelling catheter was in place for at least two
days on the Date of Event (DOE) - the date the first element used to meet criterion appears; if
the catheter is discontinued, then it’s still considered a CAUTI if the catheter was in for more
than 2 days and the DOE occurred on the date the catheter was discontinued or the day after;
If a catheter is removed and reinserted within one full calendar day or less, then the day count
continues, otherwise it resets
Source: Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-CatheterAssociated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI])— CDC, 2015
1. Fever and hypothermia are non-specific symptoms of infection and cannot be excluded from UTI
determination because they are clinically deemed due to another recognized cause
2. An indwelling urinary catheter in place would constitute another recognized cause for patient complaints of
“frequency,” “urgency”, or “dysuria” and therefore these complaints do don’t count as symptoms for purposes of
UTI determination when a catheter is in place
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How Hospitals Define UTI
•
Among those hospitals that submitted definitions, all reported either
adopting the criteria for UTIs supplied the Centers for Disease Control and
Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) or
adopting a similar version thereof

•
•
•
The University of Maryland Medical Center Midtown, Carroll Hospital Center and
MedStar Montgomery Medical Center have wholly adopted the CDC’s criteria
Among those hospitals that submitted definitions, all require a positive
culture as one of the elements needed to diagnose a UTI, and all but one
use CDC’s criteria to define a positive culture*
Among those that differentiated between catheter and non-catheterassociated UTIs, all reported using CDC’s criteria regarding catheter
placement timing to distinguish between the two
A point of differentiation is whether or not a urinalysis is required to
diagnose a UTI
*Note: The exception was Frederick Memorial Hospital (FMH), which requires fewer
Colony-Forming Units (CFU)/ml than the CDC; FMH requires > 103 CFU/ml while CDC
requires ≥105
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Other Criteria In Use
•
Other Hospitals reported using variations of CDC / NHSN criteria
Peninsula Regional Medical Center
For patients with catheters:
-Requires a positive culture AND suprapubic pain or tenderness AND microscopic
urinalysis revealing >10 WBC/HPF
For patients without catheters:
-Requires a positive culture AND requires two or more complaints or exam
determinations of the following: suprapubic pain, tenderness, frequency, urgency
or new onset dysuria
Reference: A workgroup of physicians (Urology, hospitalists, and Critical Care Medicine), IP, and coding staff; Based on the CDC
CAUTI and Non-CAUTI criterion
Anne Arundel Medical Center
For patients with or without catheters:
-Requires a positive culture AND pyuria with > 10 WBC/HPF
References: 1) “Laboratory Diagnosis of Urinary Tract Infections in Adult Patients” Clinical Inf Diseases April 2004, 38:1150
2) CDC NHSN Jan 2014
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Other Criteria In Use
•
Other Hospitals reported using variations of CDC / NHSN criteria
Johns Hopkins
Hospital Epidemiology and Infection Control (IC) staff follow CDC guidelines
-Criteria used by IC has previously included a requirement of fever and pyuria
(>10 WBC/HPF)
-As of January, 2015, infection control staff will no longer require the signs of fever
or pyuria in addition to a positive culture
Frederick Memorial Hospital
In addition to the CDC’s symptomatic/signs requirement AND a positive urine
culure:
-A urinlaysis with one of the following findings:
-Leukocyte esterase and/or nitrites
-Pyuria – urine specimen with >103 WBC/mm3 of unspun urine or
>3 WBC/HPF of spun urine
-Microorganisms seen on Gram stain of unspun urine
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Other Criteria In Use
•
Other Hospitals reported using variations of CDC / NHSN criteria
The University of Maryland Rehabilitation & Orthopaedic Institute AND
The University of Maryland Upper Chesapeake Medical Center
Patients must have a minimum of two two or more signs or symptoms:
-Urgency, frequency, dysuria, flank pain, bladder spasms, autonomic storming,
dysreflexia, now onset incontinence, fever, costovertebral angle tenderness,
suprapubic tenderness, decreased mental status, and hematuria
AND
-A urinalysis positive for pyuria - >11 WBC/HPF*)
AND
-A positive urine culture
References: 1) CDC 2) Consortium for Spinal Cord Medicine 2006 : Bladder Management for Adults with Spinal Cord Injury: A Clinical
Practice Guideline for Health Care Providers : Paralyzed Veterans of America 3) Definition Work Group: Ronald Rabinowitz, MD;
Henry York, MD; Michael Ritmiller, PA-C; David Neville CIC
*Note: UM Upper Chesapeake has a slightly different threshold for urinalysis, >10 WBC/HPF
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Workgroup Discussion
• What is our initial consensus?
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Homework
• Review the consensus we developed today with the
appropriate clinical and administrative staff at your
hospitals
• Come to our next meeting prepared to discuss their
feedback as well as any additional thoughts or research
that you may have
• Our next meeting is here, on January 28th at 830am
Thank You!!
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