Health Information Management

Q&A: Syncope due to UTI

CDI Strategies, December 6, 2012

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A: Yes, the provider would need to document that 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, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview. This article was originally published on the ACDIS Blog.



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