Rena
Subj: UTI
Date: 11/21/03 5:50:16 PM Pacific Standard Time
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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.
Rena R. Shephard, MHA, RN, FACDONA, RAC-C
Healthcare Consultant
