Assigned Code/DRG
Good morning everyone. I am trying to understand a DRG one of my coders gave me. Can you tell me what code and DRG you would assign? Thanks!
The doctor has documented "SIRS/SEPSIS/septic Shock w hypotension, increased LA, tachycardia, tachypnea, due to wound infection of gastric tube site with cellulitis".
Where does this go in your opinion?
Thanks!
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
[CCDS_pin_1inch]
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
The doctor has documented "SIRS/SEPSIS/septic Shock w hypotension, increased LA, tachycardia, tachypnea, due to wound infection of gastric tube site with cellulitis".
Where does this go in your opinion?
Thanks!
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
[CCDS_pin_1inch]
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Comments
2DX; SEPSIS, SHOCK, ETC. AND CELLULITIS
Janet Schoen, RN, Clinical Documentation Specialist
Clinical Resource Management
JSchoen@CHS-MI.com
office phone 989-583-7192
Janet Schoen, RN, Clinical Documentation Specialist
Clinical Resource Management
JSchoen@CHS-MI.com
office phone 989-583-7192
Juli
My encoder took me to 996.69, however, there is a "Coding Clinic 3rd Qrtr. 1997- Infected gastrostomy tube" which instructs as of Oct.1, 1998, that infected gastrostomy is coded to 536.41 with additional codes to identify the infection & organism. With that being said, it appears the principal dx. in this case would be the 536.41 with the cellulitis, sepsis & septic shock as secondary diagnoses.
Reference also the code book 536.41, it instructs you to use additional code to specify type of infection such as abscess or cellulitis (682.2), septicemeia (038.0-038.9) and to identify the organism (04.1.00-041.9).
Hope that is helpful! You have a GREAT day, Juli.
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
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