Sepsis and two or more diagnosis that meet PDX

lolly102412

I have a case I am following where the patient  presented to the ED with chest pain related to a pneumonia. The PN's throughout state: sepsis present on admission secondary to  UTI, pneumonia. Next line states bilateral pneumonia suspected aspiration, UTI with chronic foley catheter. Discharge summary states: sepsis secondary to UTI and aspiration pneumonia. The coder is taking this to the complication code as the PDX T83.511A with the sepsis and pneumonia as secondary diagnoses. The reason they gave for this is the coding guidelines for sepsis say to always code the complication first. Could you help explain this, does the guideline of two or more diagnosis that meet the PDX not apply, i.e. the sepsis guideline trumps the selection of principle diagnosis guideline?  Both were present on admission, and equally treated. Of further interest, the patient expired due to his respiratory failure and the pneumonia. Opinions welcomed.

evanspx@sutterhealth.org

Many considerations:

1. Does the record DOCUMENT the UTI is due to the chronic foley cathether?   The description indicates this is being assumed, and it may not be assumed.

2.  The record states the sepsis is due to UTI and PNA - I would posit that DOES provide one with the potential option to use the Sepsis as the PDX.  Based on your question, the patient 'would have  been admitted for sepsis due to PNA, UTI notwithstanding?

3.  IF the sepsis were only due to a UTI and the UTI is clearly documented as due to Foley, I'd agree the complication code must be the PDX.

4. What caused the patient to expire is not always relevant for selection of the PDX.  Rather, one looks to what is present on admission necessitating the admission.  As such, what organ failure were present at the time of admission that were perhaps due to Sepsis caused by PNA? (Acute Respiratory Failure)?   Look to what may have been stated as a consequence of the sepsis, such as acute organ dysfunction, is a factor for PDX Selection.

  Was the acute respiratory failure due sepsis with the PNA? 

5.  Is this 'severe' sepsis (Sepsis 3)?  Is the respiratory failure associated with the sepsis?  Seems likely as the PNA is stated as causing the Sepsis -  severity of conditions is sometimes a factor that can support one condition over another if/when 'competing' conditions for principal diagnosis selection.

6.  It is 'generally' true that IF/When a patient is admitted due to an infectious process and that infection is causing sepsis, then the Sepsis must be the PDX - exception being if there is a complication in the mix, such as per this discussion, or in something else is a factor in the infection causing sepsis, such as a shunt, or some other type of postoperative infection or abscess.

There is no 'easy' answer for this scenario as it entails several high level considerations of the CDI/Coding functions.

Paul Evans, RHIA, CCDS, CCS, CCS-P

evanspx@sutterhealth.org

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.”3

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.4

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

lolly102412

The documentation did link the UTI to the foley or as our coders interpret the "with" as a linking term the UTI with chronic indwelling foley was taken as the complication.  So, if I understand correctly, for future reference, a query to the provider asking if the pneumonia and subsequent respiratory failure were related to or the cause of the sepsis would have been helpful to assist in clarifying the PDX as the sepsis instead of the complication code would not have been inappropriate?  It was just confusing to me when following this case that the coder wanted to use the T83 as the PDX when the thrust of care was directed toward the pneumonia and respiratory failure. Thank you for your input and help in clarifying my confusion.

evanspx@sutterhealth.org

The word "with" or "in" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for "acute organ dysfunction that is not clearly associated with the sepsis").

UTI 'with' foley is not defaulted in a way cited per above to be coded as a complication, but the implication may be present.   See Guidelines above and note  neither the Alphabetic Index nor Tabular reference the term "uti WITH indwelling foley. Many misunderstand this guideline and apply it incorrectly. 

Regarding sepsis,  I'd 'try' to code SEVERE sepsis (R65.20) if documentation supports, and query for same if compliant to do so based on clinical evidence.  See ACDIS White Paper "How R You Coding Severe Sepsis"

Paul  415.412.9421 

Feel free to call me, if you wish.