Circumstance in which sepsis not the principal dx
OCG: sepsis (even though POA was not principal reason for admission (did not meet definition of principal)-
can anyone give an example of when this would be true?
Acute Appendicitis w rupture and peritonitis with sepsis POA. Principal: Sepsis, correct?
Thanks in advance for any responses
Comments
That's correct, sepsis will be your principal diagnosis. The only time you will not use sepsis as primary diagnosis is when there is a complication code on admission.
We also use sepsis as mcc when the sepsis is due to complication such as catheter related uti. The complication is pdx. Not sure about the 'over a month ago' situation, but I would same the same for that.
Betty
General Coding Guidelines ICD-10-CM Official Guidelines for Coding and Reporting 16. Documentation of Complications of Care- Code assignment is
based on the provider's documentation of the relationship between the condition
and the care or procedure. The guideline extends to any complications of care,
regardless of the chapter the code is located in. It is important to note that
not all conditions that occur during or following medical care or surgery are
classified as complications. There must be a cause-and-effect relationship
between the care provided and the condition, and an indication in the
documentation that it is a complication. Query the provider for clarification,
if the complication is not clearly documented.
This is advice from our vendor:RE: Endocarditis and Sepsis: If pt has infective form of endocarditis, in my view, sepsis is the principal condition and diagnosis code. Ref: Coding Guidelines for Sepsis which refer to 'localized infection' in a septic patient. Curious as to other thoughts or rationale for using an infective form of endocarditis as the PDX rather than sepsis if both are present on admit?
Paul Evans, RHIA, CCDS
There was strong clinical evidence of each acute condition, but the patients were made Comfort Care and shortly after died. In my view, the sepsis was not required be the CVA in each circumstance.