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We are having a discussion about coding UTI and we
are getting conflicting interpretation of the MDS manual. This is the scenario:
UA was collected to r/o UTI and MD started her on antibiotic after urine
collection. MD documented that resident has UTI however the lab lost specimen so
there is no back up lab result to confirm UTI. Resident had no fever but c/o
difficulty urinating. Should UTI be coded under Section I on MDS. Medical Record
coders feels that it is OK to code UTI however RAI coordinators disagree as
there was no lab test done. What do you think Rena? or other
gurus.
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