Understanding and coding MDS 3.0 Item I2300: Urinary Tract Infection (UTI) (Last 30 Days)

MDS 3.0 Item I2300: Urinary Tract Infection (UTI) (Last 30 Days)

Introduction

Purpose:
Urinary tract infections (UTIs) are common among nursing home residents and can significantly impact their health and well-being. Accurate documentation and coding of UTIs are crucial to ensure timely treatment and to avoid complications. MDS Item I2300 captures information about UTIs diagnosed in the last 30 days, ensuring proper care planning and medical oversight.

What is MDS Item I2300?

Explanation:
MDS Item I2300 identifies whether a resident has been diagnosed with a urinary tract infection in the last 30 days. UTIs may affect various parts of the urinary system, including the bladder and kidneys. This item helps determine appropriate care interventions to reduce the risk of recurrent infections and other complications, such as sepsis or kidney damage.

Guidelines for Coding MDS Item I2300

Coding Instructions:

• Only code a UTI if it was documented by a physician or other licensed healthcare provider within the past 30 days.
• The diagnosis must include documented clinical symptoms such as fever, increased frequency of urination, pain, or other relevant signs and symptoms.

For example, if a resident was diagnosed with a UTI two weeks ago with symptoms of burning during urination and treated with antibiotics, MDS Item I2300 should be marked as present.

Best Practices for Accurate Coding

Documentation:

• Ensure physician documentation clearly indicates the diagnosis and onset date of the UTI.

Communication:

• Interdisciplinary communication is key. Nursing staff should alert the physician and care team of any changes in symptoms.

Training:

• Provide ongoing education on identifying symptoms of UTIs in elderly populations.

Conclusion

Summary:
Accurate coding of MDS Item I2300 is vital for identifying residents with a recent UTI diagnosis. Proper documentation ensures the resident receives the appropriate care and helps prevent further complications.

Click here to see a detailed Step-by-Step on how to complete this item set.

Reference

• CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Pages I-12 to I-13.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item I2300 was based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Every effort will be made to update it to the most current version.