Q&A: Cause and effect relationships between UTIs and catheters

Q: I have a patient with a urinary tract infection (UTI) with pyuria and an elevated white blood cell (WBC) count. There’s also recurrent plugging of the urine catheter secondary to sediment. I know the term “with” can link two diagnoses, but that it does not represent a cause-and-effect relationship. Is a query needed in this particular case to link the UTI and Foley catheter?

A: If it appears that the UTI with pyuria and elevated WBC count was caused by a Foley catheter, we would need to query the provider and have them state in the documentation that the Foley caused the UTI.

In ICD-10-CM there are numerous combination codes that represent either two diagnoses, a diagnosis and manifestation, or a diagnosis and complication. Documentation must support the use of a combination code. According to the Official Guidelines for Coding and Reporting, the word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or in an instructional note in the Tabular List. Still, though, it does not show a “cause and effect” relationship.  

This is where things get a little tricky. Just because the word “with” can be interpreted to mean “associated with” or “due to” when it appears in the code title, Alphabetic Index, or in the instructional notes of the Tabular List, there are times when the documentation by the provider must state there is a cause and effect relationship between the two conditions and the word “with” is not enough. The words “due to,” however, would be enough.

Let’s look at an example. If the physician documents that the patient has a “UTI with a Foley catheter,” what information can be coded from that statement? The answer would be that the patient has both a UTI and a Foley. What if I said to you the patient has a “UTI due to a Foley catheter?” In that instance, I have just stated that the UTI was caused by the Foley catheter and no query would be necessary.

This issue was explicitly addressed in AHA Coding Clinic, Second Quarter 2012, p. 20. A question was posed about advice published in Coding Clinic, Third Quarter 2009, p. 9-10, regarding coding catheter-associated urinary tract infections (CAUTI) when the patient has an indwelling catheter and then develops a urinary tract infection (UTI). The question asked whether, in that situation, the coder could assign the code for a CAUTI even if the provider didn’t explicitly document the CAUTI.

According to Coding Clinic, the provider must document a causal relationship in order for the coder to capture the code for a CAUTI.

The Official Guidelines for Coding and Reporting state that “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,” and Coding Clinic advices that a query should be sent to the provider to clarify the connection between the UTI and the indwelling catheter.

Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.