Q&A: Sepsis with history of CAUTI

Question: When the patient is admitted with a diagnosis of sepsis, and the history describes a urinary tract infection related to a foley catheter, with documentation also indicating pancreatic cancer, anemia, and dehydration, “History describes a urinary tract infection related to a foley catheter, ”   I took that as in the past, not a current condition, I would think you’d have to query, since the patient has a history of UTI related to foley. How can the correct principal diagnosis be catheter-associated UTI?

A: This is a great question. There are a few different issues that need to be addressed to understand how to sequence this scenario. Although this may seem like splitting hairs, the statement “History describes a UTI related to a foley” is not the same as the patient has a past medical history of a condition. Additionally, this scenario states that the patient was admitted with sepsis. This would indicate that the patient has an infectious source.  As always, I would advise that if there were a question on whether the CAUTI is a current condition vs. a past history of a condition, query the provider.

Now that we have established the CAUTI and sepsis as current conditions, the sequencing of the CAUTI and Sepsis needs to be addressed. The first step is whether a cause-and-effect relationship has been established, the second is the present on admission (POA) status, and the third is the sequencing of the conditions.

A urinary tract infection related to a foley catheter is considered a complication of a device, as a cause-and-effect relationship has been established (“related to” is language that is considered to establish a cause-and-effect relationship). Per the Coding Clinic, and now as part of the coding guidelines for FY 2023, “There must be a cause-and-effect relationship between the care provided and the condition, and the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term ‘complication.’” (I.B.16, pg. 16).

So, the cause-and-effect relationship in this scenario has been established. If the documentation stated, “UTI with Foley,” a query would need to be sent to the provider to establish a cause-and-effect relationship as the term “with” in this scenario does not establish a cause-and-effect relationship.

Sequencing guidance comes from the coding guidelines as well: “If a causal condition is known, then the code for that condition should be sequenced as the principal or first-listed diagnosis.” In other words, the complication codes first even when sepsis is present. The complication would also need to be present on admission in order to sequence the condition as the principal diagnosis and select POA-Y.

In the index, the sequence is as follows: for [Catheter-Associated Urinary Tract Infection] CAUTI Complication->catheter->urethral->indwelling->infection and inflammation->T83.511A. This is the code you would sequence as the principal diagnosis, with sepsis as the secondary diagnosis.

However, as we know, there is almost always an exception to every rule in coding. If the patient has more than one source of infection, when an infection due to a device, implant or graft is present, Coding Clinic for ICD-10-CM/PCS, Third Quarter 2019: page 17, Sepsis due to Multiple Possible Causes, instructs: “When determining the principal diagnosis for a patient with multifactorial sepsis, the principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

This means, if sepsis and an additional source of infection are both present on admission, the sepsis (by coding guidance) would be sequenced as the principal diagnosis. The example that is used is a patient admitted with a CAUTI, PNA, and sepsis. The patient has more than one source of infection that were POA-Y as well as sepsis POA-Y. Clinically the Coding Clinic advice makes sense, as it would be difficult to determine which source of infection caused the septic state.

Editor’s note: Kim Conner, BSN, CCDS, CCDS-O, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at kconner@hcpro.com.