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October 22, 2012

Coding for Catheter Infections
For The Record
Vol. 24 No. 9 P. 25

The incidence of catheter-associated infections recently has risen, causing increased mortality, morbidity, and costs for hospitals. Because catheter-associated infections are reasonably preventable, some government agencies are reviewing these cases with more scrutiny.

The Agency for Healthcare Research and Quality has developed the Patient Safety Indicators (PSIs), a set of measures that screen for complications or adverse events patients experience as a result of exposure to the healthcare system. The PSIs provide a perspective on potential complications and errors resulting from a hospital admission and assist hospitals in assessing, monitoring, tracking, and improving the safety of inpatient care.

In addition to PSIs, hospital-acquired conditions (HACs) were created to track conditions that occurred after admission and are believed be preventable. The selection criteria for a condition to be considered in a HAC category include high cost, high volume, or both; is a complication/comorbidity (CC) or major CC (MCC) that could result in a higher-paying Medicare severity diagnosis-related group; and is reasonably preventable through the application of evidence-based guidelines.
The Centers for Medicare & Medicaid Services has identified several conditions that meet these criteria and therefore, when they are reported as a secondary diagnosis, will be demoted to a non-CC if not flagged as present on admission. The HACs and categories are reviewed and updated annually. How PSIs and HACs are related to catheter infections will be discussed in the following sections.

Central Line-Associated Infection
There are two major categories of infections due to central venous catheters: local and systemic. Local infections include exit or insertion site, port or reservoir, and tunnel infections. Systemic infections may be documented as central line-associated bloodstream infections (CLABSIs). The following ICD-9-CM codes are available for central line-associated infections:

• 999.31, Other and unspecified infection due to central venous catheter (includes central line-associated infection);

• 999.32, Bloodstream infection due to central venous catheter (includes catheter-related bloodstream infection and CLABSI); and

• 999.33, Local infection due to central venous catheter (includes exit or insertion site, port or reservoir, and tunnel infections).

Codes from subcategory 999.3 are assigned if the catheter in question is a central venous line. In other words, did the end of the catheter reach a large vein near the heart? There are several types of catheters that may be used, but for appropriate code assignment, the determination is the location of the end of the catheter. Coders should review the medical record carefully for the type of catheter (central vs. peripheral) and query the physician if necessary.

It is appropriate to list as a secondary diagnosis the specific infection, if documented, such as sepsis. Therefore, sepsis due to a peripherally inserted central catheter (PICC) line is assigned to codes 999.32, 038.9, and 995.91.

Sometimes the physician may document bacteremia due to a PICC line, which is classified to code 999.31 (AHA Coding Clinic for ICD-9-CM, 2011, second quarter, pages 7-8). This advice was published before the creation of codes 999.32 and 999.33 in October 2011. Therefore, with the new codes, it would stand to reason that code 999.32 should be assigned for bacteremia due to a PICC line.

One PSI category is “Central Venous Catheter-Related Bloodstream Infections” (PSI 7). The codes currently in this category include 999.31 and 999.32. Therefore, if a patient who is older than 18 has a secondary diagnosis of 999.31 or 999.32 that is not present on admission, he or she will qualify for PSI 7. The case would be excluded from PSI 7 if one of the following is present:

• The principal diagnosis was 999.31 or 999.32 or it was a secondary diagnosis present on admission.

• The length of stay was less than two days.

• The secondary diagnosis was present with any diagnosis or procedure code for an immunocompromised state.

• The secondary diagnosis was present with any diagnosis of cancer.

Additionally, there is HAC category “Vascular Catheter-Associated Infection” that includes 999.31 to 999.33. Therefore, anytime one of these codes is assigned with a present-on-admission indicator of N (not present on admission) or U (insufficient documentation), the condition will be excluded as a CC or MCC.

Vascular Catheter-Associated Infection
If the patient experiences an infection of a peripherally placed catheter, assign code 996.62, Infection and inflammatory reaction due to vascular device, implant, and graft. Code 996.62 includes arterial graft, arteriovenous fistula or shunt, infusion pump, and vascular catheter (arterial) (dialysis) (peripheral) (venous).

As mentioned above, the appropriate code assignment depends on the catheter location. Assign code 999.31 to 999.33 if the infection is due to a centrally placed catheter or 996.62 if it is due to a peripherally placed catheter (AHA Coding Clinic for ICD-9-CM, 2010, second quarter, page 8). Currently, neither PSIs nor HACs are concerned with code 996.62.

Infection Due to Indwelling Catheter
Infection due to an indwelling urinary catheter is assigned to code 996.64. As with all infections in the presence of a device, there must be a cause-and-effect relationship documented. If a patient is admitted with an indwelling catheter and is noted to have a urinary tract infection (UTI), the coder should not assume a link between the catheter and the UTI. The physician must clearly document the causal relationship before code 996.64 can be assigned. However, the physician should be queried regarding the cause of the UTI when a patient is admitted with both a UTI and a catheter (AHA Coding Clinic for ICD-9-CM, 2009, third quarter, pages 10-11).

However, a urostomy-associated UTI is assigned to code 997.5, Urinary complications, followed by code 599.0, Urinary tract infection site not specified. It is inappropriate to assign code 996.64 in this situation since a urostomy is not considered an indwelling catheter (AHA Coding Clinic for ICD-9-CM, 2012, first quarter, pages 11-12).

There are no PSIs related to catheter related UTIs. However, there is an HAC category, “Catheter-Associated Urinary Tract Infection.” Therefore, if 996.64 is coded along with another code showing the specific type of UTI and they are not present on admission, they will be excluded as CCs or MCCs.

Because of the implications the presence of these codes may cause, it is vitally important that coders assign them accurately and consistently based on physician documentation and supportive clinical evidence in the medical record. It may be necessary to query the physician for clarification.

Coding and sequencing for catheter infections are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.


ICD-10-CM Coding for Central Venous Catheter Infections
In ICD-10-CM, infection due to central venous catheter is classified to subcategory T80.21. A sixth character identifies the specific site of the infection and includes the following codes:

• T80.211, Bloodstream infection due to central venous catheter;

• T80.212, Local infection due to central venous catheter; and

• T80.218, Other infection due to central venous catheter.

In addition, a seventh character is required to identify the encounter, such as the following:

• A, initial encounter;

• D, subsequent encounter; and

• S, sequela.

Similar to ICD-9-CM, an additional code may be assigned to identify the specific infection such as sepsis (A41.9) in ICD-10-CM.

— AH