Long-Term Care Survey Alert
Is Your Facility Overcoding Urinary Tract Infection In Section I2?
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It may be if you haven't incorporated the January 2008 RAI manual update. The Centers for Medicare & Medicaid Services has clarified that nursing facilities should not code a urinary tract infection (UTI) at I2j if the resident doesn't have symptoms of the condition. CMS made the change in a January 2008 update to the RAI user's manual that includes numerous small clarifications affecting other sections and items. For coding UTI (p. 3-136), CMS added a sentence after the one that says, "UTI includes chronic and acute symptomatic infection(s) in the last 30 days." The added sentence reads: "Symptomatic refers to both chronic and acute infections; if symptoms are not present, do not code this item." Thus, "if the patient just has a positive urinalysis or urine culture but no symptoms, then you don't code that," explains James Marx, RN, MS, CIC, an infection control expert in San Diego. "Symptomatic can, however, include a mental status change," he adds. Another change to Section I: The update also revises the I3 title to include within the parentheses (7-day lookback except for all Quarterly Assessment forms which require a 90-day lookback). Editor's note: To review all of the changes made by the January update, go to http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/MDS20Update200801.pdf.
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