By Dr. Richard Pinson, MD, FACP, CCS
Question: Is a query for the organism necessary for a patient with a UTI and urine culture positive E. coli in the outpatient setting? Can it be coded directly from the lab report or must the provider specify E. coli as the cause?
Answer: The Official Coding Guidelines outpatient section IV.K states the following:
“For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation.”
E. coli would not be reported as the causative organism based on the culture report unless confirmed by the provider since it is not an interpreted report. Interpreted reports include such things as imaging, pathology, EKG, echocardiogram and others.
As stated in our CDI Pocket Guide, based on the 2019 AHIMA/ACDIS Query Guidelines, we would not be concerned about adding the E. coli code because we would consider it “marginal data”:
“Queries are not necessary for every discrepancy or unaddressed issue in physician documentation.”
In our view, facilities must balance the value of gaining marginal data quality benefits against the administrative burden of obtaining additional documentation as well as physician query fatigue.
If your facility has a policy requiring such specificity, then confirm E. coli as the cause with a provider realizing it tends to annoy providers unnecessarily.
The Pinson & Tang CDI Pocket Guide provides specific standardized query templates for the most common medical conditions as well as instruction on how to modify the template to fit the particular circumstances of the case in question.
Available online or hardcopy. Order both and save! Learn more here.
About the Author
Dr. Richard Pinson, MD, FACP, CCS
Dr. Richard Pinson is a physician, educator, administrator, and healthcare consultant. He practiced Internal Medicine and Emergency Medicine in Tennessee for over 20 years having board certification in both. Dr. Pinson is a Fellow of the American College of Physicians and former Assistant Professor of Clinical Medicine at Vanderbilt, and has assisted hospitals as a physician consultant for the past ten years. Dr. Pinson’s personal understanding of the mindset of both doctors and managers allows him a unique vantage point from which to promote cooperation between physicians, hospital staff, and administrators toward achieving beneficial and practical changes.