Sespsi vsrespiratory failure PDX
I have encountered a case were a patient was admitted for respiratory failure, placed on vent and treated. He was found to also meet sepsis criteria and queried the MD. No documentation regarding sepsis is found throughout the MR or DS, only on the query response. Sepsis was coded as the PDX. According to the coding department Sepsis overrules Respiratory Failure. Thank you for your input and clarification.
Comments
Sepsis, when adequately documented and with clinical support, is required to be used as the PDX rather than ARF if the sepsis was present on admission...please refer to published Coding Guidelines.
"When Sepsis and Acute Respiratory Failure both meet the definition of PDx, it is acceptable to sequence the Acute Respiratory Failure as the PDx if the documentation indicates that the acute respiratory failure is due to another condition and not associated with the sepsis (is not organ failure due to the sepsis). This must be clearly established in the medical record documentation."
The quoted advice from our CDI program vendor. I believe people get too wrapped up in making sure they code sepsis first. The systemic condition is always coded over the localized infection, but it doesn't mean sepsis is always coded first no matter what else is going on.
Having said that, I think the main question of original poster was should the sepsis be coded first with only the query for documentation. That's a good question - I would say yes too, since the doctor apparently answered yes to the query, but a payer could try to deny due to lack of documentation.
I may need to attempt to respond w/ several messages due to size restrictions. RE: Sepsis causing organ dysfunction, the Official Guidelines and multiple issues of AHA Coding Clinic state that Sepsis must be the PDS IF the acute organ dysfunction is due to Sepsis. See Official !-10 Guidelines for Sepsis as well as the coding instruction in I-10.
Having said that, I'd agree that if a pt is admitted with Sepsis and some other SEVERE condition independent of sepsis, there are rare circumstances in which something else, such as Stroke or AMI may qualify as the PDX. We have had some very unfortunate patients admitted with sepsis, stroke and cardiogenic shock due to MI. Needless to say, it was impossible to say which condition arose first, all such patients expired, and the documented circumstance of admission and w/u provided sequencing choices. My caveat would be to be cautious when sequencing the PDX as the fact that 2 or more exist does not always mean we can pick & chose.
Assigning the Principal Diagnosis -Two or more diagnoses that equally meet the definition for principal diagnosis
“In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.”
Source: ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2009 Page 91 of 112
Many patients present to the emergency department with multiple conditions that are often interrelated. In these situations, it is important to have documentation of all conditions that could result in a hospital stay for treatment and monitoring. Sequencing of the diagnoses becomes of utmost importance in ensuring that accurate reflection of the severity of illness (SOI) is documented in code assignments. The Federal Register instructs hospitals to ensure complete and accurate coding which results in accurate reporting of patient conditions, assignment of appropriate MS-DRGs, and ultimately, maximum reimbursement for the care provided to the patient.1 This means if a patient presents with multiple conditions that meet the UDHHS definition for principal diagnosis, any one of the conditions could be sequenced as the principal diagnosis, as determined by the circumstances of the admission, diagnostic workup and therapy provided. However, the fact that two or more conditions are listed as the reasons for admission does not mean a sequencing choice is always an option. When the thrust of treatment is directed primarily towards one condition, it must be used as the principal diagnosis. For example, a patient presents and the provider documents pneumonia, acute respiratory failure, and acute renal failure as the reasons for admission. If all of these diagnoses qualify for principal diagnosis selection, as stated above, it may be compliant to sequence the principal diagnosis selection so that the best or highest relative weight (RW) MS-DRG IS generated. The MS-DRGs equate to:
DRG 189 Respiratory failure RW 1.2694
DRG 193 Pneumonia with MCC RW 1.4948
DRG 682 Renal failure with MCC RW 1.6410
Considering the amount of resources used in the provision of care for this patient, it is important to sequence the acute renal failure as the principal diagnosis to best reflect the SOI and resource consumption of the patient’s condition.
As another example, a patient is admitted for both pneumonia and dehydration. The dehydration is treated with intravenous fluids and is quickly resolved on the first day of admission, whereas the pneumonia is treated with intravenous antibiotics for several days. No sequencing choice is available as the pneumonia is clearly the more significant condition and the focus of the diagnostic workup and therapy rendered.