We are seeking clarification regarding the advice previously published in Coding Clinic, Third Quarter 2009, pages 9-10, regarding the coding of catheter-associated urinary tract infection (CAUTI) when the patient has an indwelling catheter and then develops a urinary tract infection (UTI). If there is no provider documentation of CAUTI, but there is documentation that the patient has a UTI and it is noted that the patient has an indwelling catheter, can a coder automatically assign code 996.64, Infection and inflammatory reaction due to indwelling urinary catheter?
No, the provider must clearly document the causal relationship. If the provider states that the UTI is secondary to the indwelling urinary catheter, assign code 996.64, Infection and inflammatory reaction due to indwelling urinary catheter, and code 599.0, Urinary tract infection, site not specified. If the provider does not state that the urinary tract infection is due to the catheter, assign only code 599.0.
The Official Guidelines for Coding and Reporting state, “As with all procedural or postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure.”However, considering the importance of preventing and tracking CAUTIs, if the patient has an indwelling catheter and a UTI, coders should query the provider regarding the cause of the UTI and ask that the information be documented in the record (even when the cause of the UTI is not the catheter).