Sepsis vs Noninfectious Diagnosis as Principal Diagnosis?
Good Morning!
I have a principal diagnosis question for you all.
What do you do if you have Sepsis and a noninfectious diagnosis POA that are both treated, how do you determine the principal Diagnosis?
It seems like most of the time Sepsis ends up trumping most other diagnoses.
But in the cases below the patient also had a noninfectious diagnoses POA that required a surgery - so since they required a surgery should those diagnosis trump the Sepsis and be Principal Diagnosis?
Example 1.
Sepsis due to PNA
NSTEMI - found to have CAD per cardiac cath, went to OR for CABG x 3
*For this case presumed Sepsis is last written a few days after admission and then completely drops off the record once patient care is transferred to the Cardiothoracic Surgeon, the rest of the patients stay is focused on Cardiac Care.
I recommended the coder Query to see if the sepsis resolved or was ruled out.
What do you think the Principal Diagnosis should be (assuming Sepsis was ruled in and had resolved)?
Example 2.
Sepsis, had UTI.
"Septic shock resolved," noted day after admission.
Pt also had brain aneurysm that was treated surgically with a coil and that seems more so to be the focus of care.
What do you think should be the principal diagnosis?
If you know of any coding clinics or other resources that address this question, please send them my way!
Thank you,
Greta
ggoodman@virginiahospitalcenter.com
I have a principal diagnosis question for you all.
What do you do if you have Sepsis and a noninfectious diagnosis POA that are both treated, how do you determine the principal Diagnosis?
It seems like most of the time Sepsis ends up trumping most other diagnoses.
But in the cases below the patient also had a noninfectious diagnoses POA that required a surgery - so since they required a surgery should those diagnosis trump the Sepsis and be Principal Diagnosis?
Example 1.
Sepsis due to PNA
NSTEMI - found to have CAD per cardiac cath, went to OR for CABG x 3
*For this case presumed Sepsis is last written a few days after admission and then completely drops off the record once patient care is transferred to the Cardiothoracic Surgeon, the rest of the patients stay is focused on Cardiac Care.
I recommended the coder Query to see if the sepsis resolved or was ruled out.
What do you think the Principal Diagnosis should be (assuming Sepsis was ruled in and had resolved)?
Example 2.
Sepsis, had UTI.
"Septic shock resolved," noted day after admission.
Pt also had brain aneurysm that was treated surgically with a coil and that seems more so to be the focus of care.
What do you think should be the principal diagnosis?
If you know of any coding clinics or other resources that address this question, please send them my way!
Thank you,
Greta
ggoodman@virginiahospitalcenter.com