Sepsis and diabetis

renmeyer@sbcglobal.net

Good Morning

I need some CDI talk wisdom again please.

Pt has a chronic foot ulcer and noticed foul smelling drainage. Pt was diagnosed with "Infected heel ulcer,Hyponatremia, ESRD, Sepsis and has insulin dependent DM,PVD and longstanding chronic osteomyelitis. All POA. Pt has an amputation during this hospital stay. It is coded PDX, DM with specified manifisteations - 25080. DRG 616 – Amputation of lower limb.

My thought was that it would go to DRG 853 with sepsis (MRSA septicemia 03811 and 99591 was coded) as the PDX.

When I asked about it I was told "that everything that was wrong with this patient stemmed from the diabetes, including osteomyelitis and cellulitis/non-healing ulcer growing staph aureus which led to the sepsis. The definitive treatment for the ulcer, which was causing so many additional problems was amputation. And Sepsis (a condition secondary to a diabetic-related problem) could not be treated without treating the diabetic-related condition that was causing it."

I'm still not clear why the sepsis can't be the PDX. Any thoughts from the pro's?

Thanks for your input.

Renee, RN, CCDS

gwojo

Hi Renee,
 
there is a coding clinic that addresses a localized infection and a systemic infection, and the systemic infection trumps the local. This should go to 853 as you stated.
 
Fran~

kshumpert

Ah, the old which came first, the chicken or the egg conundrum! When you get to the end, all disease is a result of our birth and entirely different DRG

When I get in this nasty cycle, I review my coding guidelines and coding clinics. If there is no further guidance, I default to a single question; what precipitating event required acute inpatient care and would not be treated in an outpatient setting? This process may be different from other CDI answers due to the model that we use here.

In the below scenario, we do have chapter specific guidelines (Chapter 1.b.) for sepsis as a principal diagnosis.

Sequencing sepsis and severe sepsis
(a) Sepsis and severe sepsis as principal diagnosis
If sepsis or severe sepsis is present on admission, and meets the definition of principal diagnosis, the systemic infection code (e.g., 038.xx, 112.5, etc) should be assigned as the principal diagnosis, followed by code 995.91, Sepsis, or 995.92, Severe sepsis, as required by the sequencing rules in the Tabular List. Codes from subcategory 995.9 can never be assigned as a principal diagnosis. A code should also be assigned for any localized infection, if present.

Hope this helps!

Thanks,
Kathy
Kathy Shumpert, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Office 765-864-8754
Cell 765-431-0123
Fax 765-453-8447

Community Howard Regional Health
3500 S Lafountain
PO Box 9011
Kokomo, IN 46902

gwojo

Here is info from RAC audits:

RAC Denial: H&P and discharge summary indicate the patient was admitted with both sepsis and cellulitis. Progress notes indicate the cellulitis was the cause of the sepsis. Even though both conditions were present on admission, we cannot choose between the two as PDX in this case because the coding rules indicate that we must sequence the code for sepsis as principal diagnosis. The underlying localized infection (cellulitis) is the secondary diagnosis.

Remember Renee, if Sepsis not POA this will go to 250.80 pdx.

Fran~

renmeyer@sbcglobal.net

Thanks or your input!

renmeyer@sbcglobal.net

Lol!! - "When you get to the end, all disease is a result of our birth and entirely different DRG "
We use that model too. Except when we don't... :-)

Thanks for your input.
Renee