Q:
Our facility is triggering the UTI QM, and we have identified that many of these are the result of the hospital diagnosing a UTI that does not meet our infection criteria. Do we have to code those on the MDS if they occur during the look-back period?
A:
The RAI manual, on page I-13 states the following:
“If the diagnosis of UTI was made prior to the resident’s admission, entry, or reentry into the facility it is not necessary to obtain or evaluate the evidence-based criteria used to make the diagnosis in the prior setting. A documented physician diagnosis of UTI prior to admission is acceptable.”
You will note that this statement is worded differently than the one pertaining to UTIs diagnosed when the resident is not an inpatient which states:
“When the resident is transferred, but not admitted, to a hospital (e.g., emergency room visit, observation stay) the facility must use evidence-based criteria to evaluate the resident and determine if the criteria for UTI are met AND verify that there is a physician-documented UTI diagnosis when completing I2300 Urinary Tract Infection (UTI).”
Therefore, while you must use the evidence-based criteria for UTIs diagnosed as a hospital outpatient, it is up to your facility if you want to evaluate the UTI diagnosed during the resident’s inpatient stay using your designated evidence-based criteria. As many hospital diagnosed UTIs during an inpatient stay do not meet evidence-based criteria, it would be in your best interest to use your chosen McGeer, Loeb or NHSN guidelines to determine and support that it does not meet the criteria, and thus justify a decision that it should not be coded on the MDS and trigger the QM.
Written by: Janine Lehman, RN, RAC-CT, CLNC
Director of Legal Nurse Consulting
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