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sepsis experts - question

Posted: Jun 03, 2012

Sepsis. Diagnosis is sepsis due to pneumonia. The diagnoses are presented in this way:

Sepsis due to pneumonia

UTI due to E. Coli

Now, if you code the sepsis, it will be sepsis unspecified because you do not have an organism documented for the pneumonia or the sepsis (they don't know)038.9, 99591 and 486.

If you go to code the UTI with E. Coli, there is an edit that excludes 041.4 with 038.9. Do you put it in, or do you just leave the organism for the UTI out?

pneumonia caused the sepsis; E. coli caused the UTI - nm

[ In Reply To ..]

yes - but

[ In Reply To ..]
That is clear. What do you do about the excludes edit?

Suggestion - CCS

[ In Reply To ..]
Read the coding guidelines pertaining to sepsis. Be sure you are correct in the codes you are using. Be sure you are following the guidelines. If you are, use the codes anyway.

The flag is alerting you to the fact that "sepsis" is often used to mean "UTI." You have actual sepsis due to pneumonia. Coding that sepsis and the UTI triggered the edit, if I read your post correctly.

Edits do not tell you that you CANNOT use the codes. They just alert you to an issue with them. If you have good reason to use them, you can. Just expect that your claim may get a second look, so be very careful that you are coding it correctly and that the documentation supports the coding.

Edits in inpatient software usually parrot the guidelines and the includes/excludes notes, etc., in the ICD-9 code set. You should be able to produce the same "edits" out of your own head, but the software helps you out if your brain gets wuzzled.

Those edits are not an indication that CMS will slam the portcullis down on your claim, as it will with outpatient CPT code edits. Your software just sends a squire out to make sure you're more friend than foe. Even foes get in if they have a good reason.

If this is an inpatient stay, the doctor should know more than that. Look carefully for better documentation, for evidence of bacterial pneumonia, and query it if you need to. This is where reading those guidelines will come in handy.

"Sepsis" and "pneumonia" are kind of lame on an inpatient stay--you'd think they could do better than that. That is a clear indication that your facility needs some clinical documentation improvement activities happening.

sepsis - excludes

[ In Reply To ..]
I have read the guidelines, especially sepsis, and have them always on my toolbar. Some cases fall through the cracks.

What about excludes?: Code(s) 041.x should not be used in conjunction with 038.x per Excludes note:

04149 Other and unspecified Escherichia coli (E. coli)
[041]
Excludes: Septicemia (038.0-038.9)

I have to query a lot, but if they are not mentioning any organisms at all anywhere, I do not. Letâ��s say they say on DS Sepsis, â��probablyâ�� due to pneumonia. Both present on admission. UTI developed on day 4, so not POA, and so not cause of sepsis.

Just wondered what others do in these situations. Thanks.

What others do - sm

[ In Reply To ..]
I think you may be missing the point behind the excludes note and the posts helping you.

This is not falling through any cracks. You are just mmisunderstanding the purpose of the excludes note.

You seem to think the excludes note is saying you cannot use those codes on the same hospital stay. It isn't.

It is telling you that you cannot use them together to code ONE CONDITION. As both answers tried to tell you, you are coding TWO conditions, not one.

Not sure why you are only queryng pneumonia if an organism has been mentioned. You should be queryng if any clinical indications of a more sprcific type of pneumonia are present. There is no requirement to have a positive culture.

Thank you - Very helpful

[ In Reply To ..]
Still learning, always. That is what I meant, if there are clinical indications -opportunity for query, I do.

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