I2300: Urinary tract infection (UTI) (LAST 30 DAYS), Step-by-Step

Step-by-Step Coding Guide for Item Set I2300: Urinary Tract Infection (UTI) (Last 30 Days)

1. Review of Medical Records

• Thoroughly review the resident’s medical records for the last 30 days to identify any documented symptoms, diagnoses, or treatment related to urinary tract infections.
• Look for notes from physicians, nursing entries, lab results indicating a UTI, and medication records for antibiotics specifically prescribed for UTI treatment.

2. Understanding Definitions

• Urinary Tract Infection (UTI): An infection involving the kidneys, ureters, bladder, or urethra. For coding purposes, it includes documented and treated UTIs based on clinical symptoms and/or laboratory confirmation.
• UTIs are considered significant if they require medical treatment beyond simple cystitis.

3. Coding Instructions

• Code "1" if there is medical record documentation of a UTI in the last 30 days that required treatment.
• Code "0" if there is no documentation of a UTI or if the UTI did not require treatment within the last 30 days.

4. Coding Tips

• Ensure that the UTI diagnosis is supported by either clinical assessment (e.g., fever, urgency, pain) and/or laboratory tests (e.g., urine culture).
• Review antibiotic treatment courses to confirm they were specifically prescribed for a UTI and not for another condition.

5. Documentation

• Clearly document all instances of suspected or confirmed UTIs, including the date of onset, symptoms, diagnostic tests, and treatments.
• Record conversations with healthcare providers regarding UTI symptoms, evaluations, and follow-up care.

6. Common Errors to Avoid

• Coding a UTI based on urinary symptoms alone without proper medical diagnosis or treatment.
• Overlooking UTI documentation if the resident is asymptomatic but was treated based on lab findings.

7. Practical Application

• Example: A resident shows symptoms of increased frequency and discomfort while urinating. A urine sample is taken and sent for culture, which returns positive. The physician prescribes a course of antibiotics specifically for the UTI. The treatment begins within the 30-day window. This scenario should be coded as "1" for I2300, indicating a treated UTI within the last 30 days.

Please note that the information provided in this guide for MDS 3.0 Item I2300 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.