Urinary Tract Infections (UTIs) are a commonly miscoded data element on the MDS. Are you over coding UTIs? Are you not coding them at all? Should you? Shouldn’t you? The MDS has historically left data collectors asking themselves these questions. What happens if I do not code it, what happens if I do. As MDS completion people, our number one priority should always be accuracy. 

Let us look at the basics of coding a UTI on the MDS.   

How to Code a UTI on the MDS 

Per the RAI Manual, the following criteria need to be met to code UTI on the MDS.   

Item I2300 Urinary Tract Infection (UTI)

The UTI has a look-back period of 30 days for active disease instead of 7 days — Code only if both of the following are met in the last 30 days:

    1. It was determined that the resident had a UTI using evidence-based criteria such as McGeer, NHSN, or Loeb in the last 30 days

AND  

    1. A physician documented UTI diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days.

    Ask yourself these key questions:

      • Which evidenced-based infection control criteria does my facility utilize? 
      • Does the data that I have available meet these evidenced-based standards to support the definition of a true UTI?
        –  YES or NO
        –  If yes, continue to the next question. If no, stop here and do not code UTI on the MDS.
      • Did the Physician or Physician extender (nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) document a UTI diagnosis in the last 30 days?
        – If yes, in conjunction with the Yes above, code UTI on the MDS. 

      What About a Hospital-Diagnosed UTI? 

      Per The RAI Manual: 

      If the diagnosis of UTI was made prior to the resident’s admission, entry, or reentry into the facility, it is not necessary to obtain or evaluate the evidence-based criteria used to make the diagnosis in the prior setting. A documented physician diagnosis of UTI prior to admission is acceptable. This information may be included in the hospital transfer summary or other paperwork.

      When the resident is transferred, but not admitted, to a hospital (e.g., emergency room visit, observation stay) the facility must use evidence-based criteria to evaluate the resident and determine if the criteria for UTI are met AND verify that there is a physician-documented UTI diagnosis when completing I2300 Urinary Tract Infection (UTI). 

      The key takeaways:

        • The resident who is admitted to the hospital had a UTI before being admitted to your facility – it was not acquired in your facility.
        • The resident who is diagnosed in your facility, or while out to the Emergency department from your facility, did in fact acquire the UTI while a resident of your facility.  

      What Evidence-Based Criteria Do I Use? 

      You only need to code based on your facility’s specific infection control program, not all three.  

      Per the RAI Manual: 

      In accordance with requirements at §483.80(a) Infection Prevention and Control Program, the facility must establish routine, ongoing and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections. The facility’s surveillance system must include a data collection tool and the use of nationally recognized surveillance criteria. Facilities are expected to use the same nationally recognized criteria chosen for use in their Infection Prevention and Control Program to determine the presence of a UTI in a resident.  

      Example: if a facility chooses to use the Surveillance Definitions of Infections (updated McGeer criteria) as part of the facility’s Infection Prevention and Control Program, then the facility must use the Surveillance Definitions of Infections (McGeer criteria) to determine if the resident has met the evidence-based criteria for a UTI.  

      Need more information on your facility’s evidenced-based infection control program?  Check out:

        MDS nurses should follow their facilities’ evidence-based criteria in their Infection Prevention and Control Program for the accuracy of coding UTIs on the MDS.  

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