A patient is admitted with a urinary tract infection (UTI) resulting from E. coli. The patient has an indwelling Foley catheter after recent radical prostatectomy for prostate cancer. The coder queries the physician regarding the relationship of the UTI and the Foley catheter, and the physician documents that the UTI is caused by the Foley catheter. The patient is morbidly obese with type 2 diabetes, controlled with insulin. The patient is still under active treatment for the cancer.

Question

Quizplus · Accepted Answer

The correct coding includes T83.511A for the infection and inflammation of a genitourinary prosthetic device, initial encounter, since the UTI is caused by the Foley catheter. N39.0 for the UTI itself. B96.20 for unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere, since the specific strain of E. coli is not mentioned. E66.01 for morbid (severe) obesity due to excess calories. E11.9 for type 2 diabetes mellitus without complications, controlled with insulin (Z79.4 indicates long-term (current) use of insulin). C61 for malignant neoplasm of prostate, indicating active treatment for prostate cancer. Y84.6 for the presence of the indwelling catheter.

A Patient Is Admitted with a Urinary Tract Infection (UTI)