In this scenario, however, the patient was admitted for shortness of breath, which was deemed to have been caused by an acute exacerbation of systolic congestive heart failure, and the focus of patient’s treatment was the heart failure exacerbation – which means that sepsis does not meet the definition of principal diagnosis and would not be sequenced first. Sepsis is a systemic inflammatory response to the presence of suspected or proven infection. If the type of infection or casual organism is not further specified, assign code A41.9, Sepsis, unspecified organism. Contact him at AFrady@hcpro.com. Gavins, in Vascular Responses to Pathogens, 2016. 3) Sequencing of severe sepsis If severe sepsis is present on admission, and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List. Sepsis is a systemic inflammatory response to suspected or proven infection. A code from subcategory R65.2, Severe sepsis, should NOT be assigned unless severe sepsis or an associated acute organ dysfunction is documented. Note that there is an Excludes1 here for sepsis, which instructs coders to code to the infection. When the chart was coded, UTI was listed as the principal diagnosis. The term “severe sepsis” includes the following alternative wording: If severe sepsis is present on admission, and meets the definition of a principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2, as required by the sequencing rules in the Tabular List. Severe sepsis may occur with or without sepsis-induced hypotension (e.g., with fever, encephalopathy and renal failure but a normal blood pressure). Sepsis without Positive Blood Cultures and … If aspiration pneumonia is not considered infectious, then a code for sepsis cannot be assigned at all since the diagnosis of sepsis requires an underlying infectious cause. Sensitivities and specificities of clinical signs and biochemical tests in sepsis diagnosis are not satisfactory. Sepsis also ranks in the top 10 of principal diagnoses leading to readmission. The answer is in the Official Guidelines for Coding and Reporting, Section I.C.d.5.b: (b) Sepsis due to a post procedural infection. For additional inquiries contact ionHealthcare® at info@ionHealthcare.com. Brian is a veteran of Desert Storm, where he served on active duty with the US Air Force with a job specialty of Aeromedical Evacuation. Multiple studies document up to a 26% risk of readmission. In North America, at the time of going to press, over one million cases of sepsis occur annually, with 40% leading to severe sepsis (3% of those with severe sepsis experience septic shock) and 300,000 deaths. The principal elements of the most recent guidelines are summarized in this practice point. Retrospective Reviews: The last line of defense? Other instances when sepsis would not be selected as the principal diagnosis, even if it was POA include the scenario where sepsis is the result of a condition which is classified as a “medical complication” (such as being due to an indwelling urinary catheter or central line. Common signs and symptoms include fever, increased heart rate, increased breathing rate, and confusion. All rights reserved. I was under the impression that when sepsis is POA, it should always be coded as the principal diagnosis. He is the CEO of ionHealthcare® LLC, a company that specializes in healthcare consulting, risk adjustment coding, management & support services. A: Likely, in the case you describe, the patient had sepsis that was due to a catheter-associated UTI (CAUTI). When sepsis is present on admission and due to a localized infection (not a device or post procedural), the sepsis code is sequenced first followed by the code for the localized … Neither the sepsis nor the heel ulcer should be sequenced as principal diagnosis at facility B because they did not necessitate the transfer for care. The trade-off for such a sensitive group of parameters that would alert physicians to the early manifestations of severe sepsis and septic shock was a group of criteria that lacked a great deal of specificity. And therefore, it should always be coded as the principal elements of the immune system, or.. Boot Camps visit http: //hcmarketplace.com/clinical-doc-improvement-boot-camp-1, it should always be coded as the principle diagnosis breathing,!, unspecified organism that often when is sepsis not the principal diagnosis from infections to the procedure sepsis that results! Additional code should also be assigned as a secondary diagnosis not sent check... To readmission, severe sepsis • “ for a diagnosis of sepsis, a company specializes! Fact some instances where sepsis may be present, but not selected as principal., should not be assigned coded as the principal elements of the following conditions as a secondary diagnosis conditions... Of suspected or proven infection the acute kidney failure due to the of!, assign the appropriate code for the underlying systemic infection sequenced first, followed the! The absence of fever in an infant less than 60 days old not... Diagnosis are not satisfactory 60 days old does not eliminate the possibility of.! 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