May 7, 2012

Correctly Coding Catheter Infections
By Judy Sturgeon, CCS, CCDS
For The Record
Vol. 24 No. 9 P. 8

Section 5001(c) of the Deficit Reduction Act of 2005 mandates that Health and Human Services (HHS) identify hospital-acquired conditions (HACs) that are high cost, high volume, or both; result in the assignment of the case to a diagnosis-related group (DRG) that has a higher payment when present as a secondary diagnosis; and could reasonably have been prevented through the application of evidence-based guidelines.

The current list of HACs features 10 conditions. Since October 2008, each has had the potential to affect Medicare DRG payment on individual inpatient claims. Beginning July 1, nine of them will have the potential to affect Medicaid payment. In addition, as part of the adoption of the fiscal year 2011 Inpatient Prospective Payment System final rule, the Centers for Medicare & Medicaid Services (CMS) announced eight of the 10 HACs will be included in the Hospital Inpatient Quality Reporting program. Anyone can access the resulting Hospital Compare website and review comparison data on the HAC measures for any three participating inpatient facilities in proximity to each other.

Every time a claim is sent to Medicare or Medicaid, the DRG is recalculated after removing any HAC diagnosis codes that were either not present on admission or were unknown if present on admission. If the removal of a code reduces the DRG, then the associated payment is lowered accordingly.

Because this issue affects everyone from coding managers and quality staff to chief financial officers and the CMS itself, let’s examine some of the reasons these conditions are difficult to code.

Two of the most widely reported HACs are vascular and urinary catheter infections. While there is more than one code for each of these diagnoses, only codes 999.31 (Infection and inflammation due to an indwelling urinary catheter) and 996.64 (Infection and inflammation due to central venous catheter) are reportable.

To correctly code and report a patient’s condition, the physicians’ documentation must validate the site and type of catheter, that the infection was caused by the catheter, and whether the diagnosis or its symptoms were present on admission.

Site and Type
Not all urinary catheters qualify as HACs. The index and tabular of ICD-9-CM are specific that the line must be indwelling (ie, left in place in the bladder). This may be a urethral catheter such as a Foley or it may be a suprapubic catheter if the patient’s medical condition requires this type of insertion. These catheter infections, which code to 996.64, are potential quality issues.

Coders must not assume that every documentation of “urinary tract infection due to catheter” automatically assigns to code 996.64. A catheter described as a Foley does not necessarily correlate to indwelling status. While the indwelling urinary catheter is likely to be a Foley, the same kind of catheter may be used for intermittent self-catheterization for one-time, in-and-out urine sample collection as well as other uses.

Prudent coders must read the progress notes to determine how long the patient has had the catheter and be certain that it meets the definition of indwelling before reporting it as such. Other infections caused by nonindwelling urinary catheters would be assigned to code 996.65, Infection and inflammatory reaction due to other genitourinary device/implant/graft. This code is not an HAC-reportable condition even if it was not present on admission. Conscientious coders will assign the correct code for the patient’s actual condition to avoid incorrect overreporting of HACs associated with the facility.

Just like Foley catheters are not necessarily indwelling, not all venous catheters are central lines. It is important to code and report key indicators correctly, but it is equally important not to report a case as being an HAC when it does not meet HHS criteria to be of significant concern. While central venous catheters are assigned to code 999.31, there are peripheral IV lines and other types of vascular accesses that are coded elsewhere in ICD-9-CM.

The ICD-9-CM index and tabular says descriptors such as Hickman, portacath, triple lumen, PICC, and umbilical venous catheters indicate types of central lines, but those are only examples, not an all-inclusive list. If coders need documented validation regarding other types of catheters, they may wish to ask a physician if other lines such as permacaths, tunnelled catheters, and internal jugular and femoral vein catheters are always considered central venous catheters. Doing so can eliminate the need to query every such case and avoid committing a compliance violation.

Cause
The fact that a patient with a catheter has a lab sample positive for bacteria and receives antibiotics does not permit coders to presume the device caused the infection. Official Coding Guidelines and dozens of Coding Clinic examples demand that cause and effect of medical complications must be clearly documented by the provider.

The abbreviations CAUTI (catheter-associated urinary tract infection) and CLABSI (central line-associated bloodstream infection) are becoming quite popular. If a facility does not recognize these as official abbreviations, coding directors should update their policy. Unless documented as such at discharge, even possible/probable cause statements do not allow the use of the complication code. Documentation that is ambiguous or confusing requires that the physician be queried for clarification.

Present on Admission
Even if the diagnosis must be coded as an HAC target code, it will only threaten the DRG and quality indicators if it was not present on admission. Coders should know the present-on-admission rules and when the symptoms that led to the postadmission diagnosis were present on admission. If coders cannot tell whether the problem was present on admission, they can document it as “U” (unknown) or the provider can be queried. If the provider documents that the time of onset is uncertain, the correct present-on-admission designation becomes “W” for clinically undetermined. While U is considered an HAC-reportable diagnosis, W is not, so be certain to consider adding this scenario to the coding department’s list of query-worthy criteria.

Other Issues
If an HAC diagnosis is not present on admission, the code must be sequenced in reporting spaces 2 through 9 on the CMS claim form. Negligence during sequencing can result in the code failing to be considered by the CMS on DRG assignment and in public reporting. Before completing the coded abstract, coders should make sure that HAC diagnoses are sequenced in the top nine data fields for correct reporting, payment, and monitoring.

While coding becomes more challenging every time another task is added by federal reporting mandates, so too does the value of a coder’s skills. Continue to learn your craft and hone your skill. This is not just another job; it is a career that demands both talent and craft, and rewards those who accept and overcome its challenges.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 21 years.