Q&A: Syncope due to UTI

Q: A patient with a long history of Type I diabetes is admitted after a syncopal episode. Urine culture grows greater than 100,000 E. coli, and the physician documents a diagnosis of urinary tract infection (UTI) treated with PO Bactrim. If the physician documents the diagnosis and the treatment then why would the principal diagnosis revert to a syncope symptom code if the patient’s workup is completed? Is the principal diagnosis syncope because the physician did not state the correlation between syncope and the UTI?

A: Yes, the provider would need to document the UTI was present on admission (POA) and/or state a relationship between the syncope and UTI thus demonstrating the UTI is the condition after study that occasioned the admission in order for the UTI to be the principal diagnosis.  As currently documented, UTI would be a secondary diagnosis, which is a CC, but it will not impact the DRG assignment because the DRG association with syncope is a single tier DRG so it does not allow movement with the capture of a CC.  While it may seem reasonable that a relationship between the UTI and syncope exists, neither coders nor CDI professionals are allowed to assign codes based on assumptions. The provider must explicitly state a relationship and/or that the UTI was POA. This scenario demonstrates the role of the CDI staff for clarifying the relationship with UTI and syncope and/or if the UTI was POA.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, answered this question. At the time of this article's original release, she was the CDI Education Director for HCPro Inc.