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There’s no “one size fits all” code for HACs. In the case of UTI, coders must first explore the medical record to determine if the infection was present on admission. Next, they must ask was the infection related to a catheter inserted in the hospital? Or was it unrelated to the catheter insertion? Ultimately, if the documentation is unclear and the physician is not properly queried, the probability for an inaccurately coded UTI increases dramatically.

There’s no “one size fits all” code for HACs. In the case of UTI, coders must first explore the medical record to determine if the infection was present on admission. Next, they must ask was the infection related to a catheter inserted in the hospital? Or was it unrelated to the catheter insertion? Ultimately, if the documentation is unclear and the physician is not properly queried, the probability for an inaccurately coded UTI increases dramatically.

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