Q&A: Querying for a CAUTI

Q: One of my physicians recently documented this statement “urine MRSA positive, but patient asymptomatic and vital signs stable, likely colonization from chronic catheter.” Based on this documentation, could we code a catheter-associated urinary tract infection (CAUTI)?

A: The first step would be to query and verify if the documentation is in reference to a chronic urinary tract infection (UTI) related to a catheter at all. Then, it’s important to understand that colonization does not mean infection.

In order to write the query, look to see if the patient has symptoms of a UTI, such as dysuria, flank pain, fever, or elevated white blood count. Look at what treatment the patient is receiving as well.

Asymptomatic and noted colonization via catheter don’t provide enough clinical indicators to query and the statement is likely the clinician’s approach to ruling out a UTI. As it stands, this is not a diagnosis one would code as there is no actual documentation of a UTI and coding professionals cannot code based on clinical indicators alone; only a physician can make the diagnosis.

Editor’s note: This question and answer were adapted from a thread on the ACDIS Forum. To learn more about participating on the Forum, click here.