Flu with pneumonia, with Sepsis
How are you coding this?? We have so many people interpreting the guidelines differently.
I have a patient with Acute respiratory failure, sepsis, Influenza A with pneumonia, AKI and others dx. I am leaning toward 487.0 Influenza with pneumonia but I don't know what to do with the sepsis. Can I code 03.89 becasue I have pneumonia as well as the flu?? Any guidence would be appreciated.
I have a patient with Acute respiratory failure, sepsis, Influenza A with pneumonia, AKI and others dx. I am leaning toward 487.0 Influenza with pneumonia but I don't know what to do with the sepsis. Can I code 03.89 becasue I have pneumonia as well as the flu?? Any guidence would be appreciated.
Comments
Coding Clinic, Fourth Quarter 2011 Pages: 110-114 Effective with discharges: October 1, 2011
Effective October 1, 2011, codes in subcategory 488.1, Influenza due to identified novel H1N1 influenza virus, have been retitled to state "Influenza due to identified 2009 H1N1 influenza virus." The 2009 pandemic influenza is now regularly referred to as 2009 H1N1 influenza, rather than novel H1N1 influenza. Additionally, a new subcategory and new codes have been created to describe novel influenza A. The new codes include Influenza due to identified novel influenza A virus with pneumonia (488.81); Influenza due to identified novel influenza A virus with other respiratory manifestations (488.82); and influenza due to identified novel influenza A virus with other manifestations (488.89). These revisions were recommended by the Centers for Disease Control (CDC) and the National Center for Immunization and Respiratory Diseases (NCIRD).
There are two major kinds of influenza viruses, types A and B. These human influenza viruses spread in people and are the cause of seasonal flu epidemics each year. In the spring of 2009, a new strain of influenza A H1N1 virus emerged, causing the first influenza pandemic in more than 40 years.
Influenza A viruses can be broken down into subtypes that are based on two proteins on the surface of the virus: the hemagglutinin (H) and the neuraminidase (N). There are 16 different hemagglutinin subtypes and 9 different neuraminidase subtypes. Influenza A viruses can be further broken down into different strains. Current subtypes of influenza A viruses found to be transmitted in people are influenza A H1N1and influenza A H3N2 viruses. Over the course of a flu season, subtypes of influenza A viruses can circulate and cause illness. In addition, influenza viruses are constantly changing through a process called "antigenic drift."
Influenza due to identified novel influenza A virus is a nationally reportable disease. It includes all human infections with influenza A viruses that are different from currently circulating human influenza viruses. These include viruses subtyped as nonhuman in origin, and those that are unsubtypable with standard laboratory methods.
Similar to the guidelines for coding HIV and avian influenza infection, codes 488.81 to 488.89 should be assigned only for confirmed cases of novel influenza A virus. Codes 488.81-488.89 are not assigned when the final diagnostic statement indicates that the infection is "suspected," "possible," "likely," or "questionable." This is an exception to the hospital inpatient guideline that directs the coder to assign a code for a diagnosis qualified at the time of discharge as suspected or possible as if it were established. Refer to the Official Guidelines for Coding and Reporting Section 1.C.8.d. for additional information.
Question:
The ICD-9-CM Alphabetical Index does not have an entry for H1N1 or swine flu. The Index does have an entry for novel A/H1N1 and novel (2009) H1N1. When a physician documents "swine flu" or "H1N1," is it appropriate to assign the code for novel (2009) H1N1, 488.1? Or should 487.1 be assigned?
Answer:
There are several different strains of H1N1 influenza viruses, including some that are responsible for the seasonal flu. If the physician documentation is not specific regarding "novel H1N1" or "novel A/ H1N1" or "2009 H1N1" influenza, or "novel influenza A," coders should not assign codes from subcategory 488.1, Influenza due to identified 2009 H1N1 influenza virus or 488.8, Influenza due to novel influenza A, without physician clarification. Instead, assign code 487.1, Influenza.
Juli Bovard RN CCDS
Jbovard@regionalhealthcom
605-755-8426
A copy of CC's response to a similar question is copied below.
Influenza with pneumonia, septic shock, renal failure and MI
Coding Clinic, Second Quarter 2005 Page: 18 to 19 Effective with discharges: July 10, 2005
Related Information
Question:
A 91-year-old man was admitted to the hospital with acute influenza and altered mental status. His condition deteriorated after admission and he developed a clinical picture of septic shock, pneumonia and hypotension, which was followed by acute myocardial infarction (AMI) and acute renal failure (ARF). We are unsure if code 038.9, Unspecified septicemia, should be assigned along with code 995.92, Systemic inflammatory response syndrome due to infectious process with organ dysfunction, and code 785.52, Septic shock, for the septic shock with multi-organ failure, since the physician did not explicitly document severe sepsis. The advice published in Coding Clinic Fourth Quarter 2003, page 73, seems to imply that severe sepsis is presumed in a patient with septic shock and organ failure. How should this case be coded?
Answer:
Note from 3M:
As of October 1, 2006, further revisions have been made to subcategory 995.9. See Coding Clinic, Fourth Quarter 2006, pages 112-113.
Note from 3M:
According to Coding Clinic, First Quarter 2006, page 18, assign code 487.0 instead of 487.1 for influenza with pneumonia.
Assign code 487.1, Influenza, With pneumonia, as the principal diagnosis, since this was the reason for the admission. The patient developed septic shock after admission. Code 038.9, Unspecified septicemia, should be assigned along with code 995.92, Systemic inflammatory response syndrome due to infectious process with organ dysfunction, and code 785.52, Septic shock, for the septic shock with multi-organ failure as additional diagnoses. Additionally, assign codes 584.9, Acute renal failure, unspecified, for the ARF and 410.91, Acute myocardial infarction, Unspecified site, initial episode of care, for the AMI.
The Official Guidelines for Coding and Reporting, Septicemia, Systemic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis, and Septic Shock, previously published in Coding Clinic First Quarter 2005 pages 28-30, specifically state, "When sepsis develops during the encounter (it was not present on admission), the sepsis codes may be assigned as secondary diagnoses, following the sequencing rules provided in the Tabular List."
"Septic shock is a form of organ dysfunction associated with severe sepsis. A code for the initiating underlying systemic infection followed by a code for SIRS (code 995.92) must be assigned before the code for septic shock. As noted in the sequencing instructions in the Tabular List, the code for septic shock cannot be assigned as a principal diagnosis."
"Septic shock cannot occur in the absence of severe sepsis. A code from subcategory 995.9 must be sequenced before the code for septic shock. The use additional code notes and the code first note provide sequencing instructions."
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
Deanne Wilk, BSN,RN,CCS
AHIMA approved ICD-10-CM/PCS Trainer
Clinical Documentation Improvement and Inpatient Coding Manager
HIMS Department
Good Samaritan Health System
4th & Walnut Sts
Lebanon, PA 17042
dwilk@gshleb.org
Phone: 717-270-4804
Cell: 717-679-7926
PNA with or due to Influenza is 487.0 - a VIRAL pneumonia. This is not coded to 486 at all.
A pt that is septic 2/2 to a viral etiology is not coded to 038.xx as this the code set used to report a bacterial sepsis.
If patient presents with influenzal and bacterial infections causing sepsis, then 038.xx might be used as the principal diagnosis.
If pt presents with influenzal pneumonia and then develops a bacterial sepsis AFTER the admission, the 038.XX is used as a secondary code.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org