Pdx question

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
Scenario: Elderly patient is admitted with overwhelming sepsis. She was admitted for 2 days before transitioning to Comfort Care and dying. The H&P, PN and D/C summery all state that the likely/probable source for the sepsis is PNA and xray supports that the patient does have PNA (Cx are negative). However, she also has a chronic hickman as well as a UTI and Sacral Decub and they state that these cannot be ruled out as the source either. They never pull the hickman or anything. She is on broad spectrum ABX prior to moving to comfort care.

I am reviewing this post-coding and the coder is stating that the possible catheter (hickman) infection must be coded as primary as it is a complication code. Is this true? I realize that a post-op infection always is coded first, but I haven’t seen anything specifically related to this issue before. I admit that I have not “done my research” on this and was just hoping someone could verify that this is correct “off the top of their head”. I KNOW this will later be scrutinized by med-staff as the coding appears to be very strange and places us in the “other circulatory illness” DRG rather than Sepsis.

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    If the record states the 'most likely source' of the Sepsis is the PNA, the sepsis is the PDX.
    Your scenario does not state the catheter is causing the UTI? Unless the record states at the time of discharge that the urinary catheter is associated with the UTI, the complication code for the indwelling catheter causing an infection should not be coded.

    Even if the record were to state there is an association between the catheter and the UTI, given your scenario states the record repeatedly documents the most likely source of the sepsis is the PNA, the code for 038.X would be the Principal, in my opinion.

    Paul Evans, RHIA, CCDS

  • ssalinasssalinas
    edited May 2016
    If the sepsis had been definitively sourced to the hickman, then yes, you would have to use the complication code as the principal dx. However since the physician said the sepsis was likely secondary to pneumonia, I would use 038.x as the principal dx.

    It is not just post-op infections that have to be coded as principal when present on admission - it is any complication.

    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    213-250-4200 Extension 3336

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Sorry Paul. She did not have a foley POA. They said that they could not rule out the Hickman as a source (or UTI, or decub).

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    This is what I thought. It would be one thing if they were all equally likely. But the record clearly states that they think the sepsis is due to the PNA but that there are other possibilities that have not been ruled out.

    Thanks for your responses!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

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