H0100B: External Catheter, Step-by-Step
Step-by-Step Coding Guide for H0100B: External Catheter
1. Review of Medical Records
Objective: Identify if the resident has used an external catheter during the assessment period.
Actions:
- Access the resident’s medical records, including nursing assessments, physician orders, and voiding or catheterization flow sheets.
- Confirm the use of an external catheter within the past 7 days. This includes any documentation of application or removal, as well as care and monitoring for its use.
2. Understanding Definitions
H0100B: External Catheter: This refers to a catheter that is placed externally to collect urine. Examples include:
- Condom catheter (for male residents), which is placed over the penis and connected to a drainage system.
- Urinary pouch (for female residents), which is designed to collect urine externally.
Illustration 1:
- Scenario: A male resident is using a condom catheter for urine collection during the 7-day look-back period.
- Result: H0100B is coded "Yes" to reflect the use of an external catheter.
3. Coding Instructions
Step-by-Step:
- Step 1: Review the medical records to confirm whether an external catheter was used at any time in the past 7 days.
- Step 2: Verify that the external catheter is documented as being used for urine collection, not for temporary or one-time procedures.
- Step 3: If the external catheter was used during the look-back period, check H0100B as "Yes".
- Step 4: If no external catheter was used, check H0100B as "No".
Illustration 2:
- Scenario: A female resident is using a urinary pouch due to incontinence, and the device was documented as being used regularly during the look-back period.
- Result: H0100B is coded "Yes" to document the use of an external urinary pouch.
4. Coding Tips
- Exclude Diagnostic Procedures: Do not code H0100B if the external catheter was used for a one-time diagnostic procedure or for temporary urine collection (e.g., for specimen collection).
- Check for Ongoing Use: Only code “Yes” if the external catheter is part of the resident’s regular care and was used during the assessment period.
5. Documentation
Objective: Ensure the use of an external catheter is properly documented in the resident’s care plan and medical record.
Actions:
- Document the type of external catheter used (e.g., condom catheter or urinary pouch) and how frequently it is applied or replaced.
- Record any related care instructions (e.g., skin monitoring for irritation, device maintenance).
Illustration 3:
- Scenario: A male resident has been using a condom catheter for urinary incontinence. The care plan includes monitoring for skin irritation and regular changes of the catheter.
- Documentation: Ensure that the use of the external catheter and care plan are clearly noted in the medical record, and H0100B is coded "Yes".
6. Common Errors to Avoid
- Misclassifying Internal Catheters: Ensure that only external catheters are coded under H0100B. Internal catheters (e.g., indwelling catheters) are coded under a different item (H0100A).
- Incomplete Documentation: Do not code H0100B unless there is clear documentation of regular use and care of the external catheter during the look-back period.
Illustration 4:
- Scenario: A resident’s chart lists the use of a Foley (indwelling) catheter, not an external catheter.
- Error: Do not code H0100B for internal catheter use. The correct code for indwelling catheter is H0100A.
7. Practical Application
- Example 1: A male resident with urinary incontinence uses a condom catheter throughout the 7-day look-back period. H0100B is coded "Yes".
- Example 2: A resident uses an external catheter once for a urine sample. Since this was a one-time use, H0100B is coded "No".
Please note that the information provided in this guide for MDS 3.0 Item set H0100B 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.
