ICD-10-CM Inpatient Coding Insight: Confirming VRE UTI with Hematuria

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Inpatient Coding – VRE UTI with Hematuria

Case Scenario

Alright, let's break down this inpatient coding scenario. We've got a 68-year-old male with a pretty complex history, who walks in with hematuria.

Patient Profile:

  • Age/Gender: 68-year-old male

  • Past Medical History: Chronic Foley catheter use, E. coli ESBL bacteremia (history), hypertension, CKD Stage III

Chief Complaint:

  • Hematuria (blood in the urine)

History of Present Illness:

Patient comes into the emergency department with visible blood in his urine (yes, hematuria), plus some urgency and mild lower abdominal pain. After digging deeper, the provider discovers the patient has a chronic Foley catheter in place. To make things even more interesting, urine cultures come back positive for Vancomycin-Resistant Enterococcus (VRE).

Medications Administered:

  • Zyvox (linezolid): Started for the VRE UTI (yep, that's the big hitter for this infection)

  • Merrem (meropenem): Continued for his history of E. coli ESBL bacteremia (better safe than sorry)

Progress Notes:

Provider documents the VRE UTI multiple times in the daily progress and infectious disease (ID) notes.

Case Discussion:

So here's the deal. A coder is looking at this case and sees a VRE UTI noted, but isn't 100% sure if it's fully confirmed. It's the only complication/comorbidity (CC) in the record, so there’s some doubt about whether this should be coded or not.

Coding Guidance:

VRE UTI

Since the patient is actively being treated for VRE UTI with Zyvox (linezolid), a targeted antibiotic for VRE infections, this diagnosis is well-supported both by clinical documentation and actual treatment.

Here’s the code you’ll need:

  • Z16.21 — Resistance to vancomycin

E. coli ESBL Bacteremia

Now, the patient also has a history of E. coli ESBL bacteremia. But unless there's active infection or treatment for it right now, don’t code it. Merrem (meropenem) is being used, but it’s a precautionary measure rather than because of active bacteremia.

Clinical Clue

It’s also super important to check if the Foley catheter is contributing to the UTI. The patient has a chronic Foley catheter, so this might actually be a catheter-associated UTI (CAUTI).

Here’s what you need to think about:

  • If the Foley catheter is indeed the cause, you could be looking at N39.0 (UTI, unspecified) or T83.511A (infection due to internal prosthetic device, initial encounter).

So, make sure to double-check the documentation for any mention of this causal link.

Takeaway:

In this case, VRE UTI is confirmed by both documentation and treatment (Zyvox), so Z16.21 is your go-to code for the vancomycin resistance. Always rely on clear clinical documentation and treatment evidence to back up your diagnosis.

And remember, make sure to carefully review any complications related to the Foley catheter to capture the right code for a catheter-associated UTI if applicable.

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