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Inpatient Coding Exercise: Complicated UTI

Discharge Summary

Admission date: 6/3/11

Discharge date: 6/6/11

Discharge diagnoses: Complicated UTI with E. coli improved at discharge. Atrial fibrillation, continue medication at nursing home. Multiple sclerosis, continue same orders at nursing home, neurogenic bladder with bladder spasm, worked up by consultant, changed Foley. Hypertension: continue maintenance medication per nursing home medication orders.

Condition at discharge: Stable.

Chief complaint, history of present illness and physical examination: Please refer to admission H&P. For Lab values, refer to chart.

Hospital course: An 87-year-old- female nursing home patient with chronic indwelling catheter, had a diagnosis of UTI, was started on IV Rocephin. She was noted to have bladder spasm and was seen in consultation. The Foley catheter was changed, it showed infection so added a Ceftriaxone and she improved. She had an abdominal series, which was negative. At the time of discharge, she was afebrile. O2 saturation was greater than 90%. Bladder spasms had improved. She was felt to have met maximum benefit of this hospitalization for Foley-related UTI, and she was felt to be a candidate for discharge back to the nursing home.

Code Assignments

ICD-9-CM Codes

ICD-9-CM Descriptions

ICD-10-CM/PCS Codes

ICD-10-CM/PCS Descriptions


Infection and inflammatory reaction due to internal prosthetic device, implant, or graft, due to indwelling catheter. "Use additional code to identify infection."


T83.51 Infection and inflammatory reaction due to prosthetic device, implant, or graft urinary system.


Check seventh digit options, which are as follows: A-initial encounter, D-subsequent encounter, and S-sequela. Since the patient has a chronic indwelling catheter, D was assigned as seventh digit. "x" placed in sixth holding position. Direction "Use additional code to identify infection" D: subsequent.


Urinary tract infection, site not specified. "Use additional code to identify organism."


Urinary tract infection, site not specified. "Use additional code to identify  infectious agent."


Escherichia coli [E. coli]


Escherichia coli [E. coli]  as the cause of diseases classified elsewhere


Atrial fibrillation


Atrial fibrillation


Essential hypertension, unspecified


Essential (primary) hypertension


Do not code 596.9 (spastic) is a non-essential modifier; in the alphabetic index: neurogenic, bladder (spastic); therefore not coded separately.


Do not code N33 (bladder disorders in diseases classified elsewhere). Excludes 1 note indicates neurogenic bladder and instructs coder that only one code is necessary; therefore do not code N33, report N31.9.


Neurogenic bladder, NOS


Neuromuscular dysfunction of bladder, unspecified: "Use additional code to identify any urinary incontinence."


Multiple sclerosis


Multiple sclerosis






Insertion of indwelling urinary catheter


Foley catheter change. Procedure alpha index: change, device, urethra.

Go to OT2DX. In the tabular:

O: Medical-surgical

T: Urinary system

2: Change

D: Urethra

X: External

O: Drainage device

Z: No qualifier

 Carol Spencer is a senior healthcare consultant with MedLearn, Inc., St. Paul, MN, and an AHIMA-approved ICD-10-CM/PCS trainer.

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