Bacteremia as PDX when the Blood culture comes back as a contaminant

crivera0516

Scenario: Pt called back to the ED for a positive Bld Cx taken the day before. Patient admitted and put on I.V ABX. The re-culture comes back negative and the positive blood culture from the day before was deemed a contaminant. Abx stopped and the patient is discharged. Can Bacteremia still be uses as PDX even though the blood culture was a contaminant?

evanspx@sutterhealth.org

Since there is no clinical bacteremia, no form of bacteremia should be coded.

crivera0516

Thanks Paul. I do see a argument for the bacteremia though. Physicians are required to treat positive blood cultures. At the time of admission, there was a positive blood culture. Although the culture was deemed a contaminant after study, the patient was treated for bacteremia that was present on admission.

proddy@clarionhospital.org

what is the primary diagnosis "after careful study".  Without Bacteremia, does it leave anything to code for a primary dx?

morris-jeff@CooperHealth.edu

I would see an argument for bacteremia if the patient was treated based on the initial blood culture for the appropriate length of time. We see this many times in pediatrics. There will be a positive culture (probably a contaminant) and based on age or comorbid conditions the patient will be treated with IV antibiotics for the appropriate length of time based on the pathogen.

Thanks, Jeff

crivera0516

How about Z code Z03.89?

evanspx@sutterhealth.org

Sorry, the condition does not exist...there is no Bacteremia; thus, no code for bacteremia.

katysuegood@gmail.com

if it was still on the differential at discharge, you could code it. But if the condition is ruled out, it cannot be coded at all, let alone as Pdx....

Katy

evanspx@sutterhealth.org

Year:	2017
Issue:	Fourth Quarter
Title:	Z Code Update, p 27
Body:	Volume 4         Fourth Quarter Number 4         2017, Page 26   ICD-10-CM NEW/REVISED CODES   Summary explanations of the Fiscal Year 2018 (FY 2018) ICD-10-CM changes effective October 1, 2017 are provided below. Addenda changes demonstrating the specific revisions to the code titles or instructional notes are not included in the explanations below. The official ICD-10-CM addenda has been posted on the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics website at http://www.cdc.gov/nchs/icd/icd10cm.htm.   There are 360 new ICD-10-CM codes implemented on October 1, 2017. In addition, 141 codes have been deleted and 226 code titles revised.   Z Code Update New Z codes have been created as noted below.   Observation The Excludes1 note at category Z03, Encounter for medical observation for suspected diseases and conditions ruled out, referring “newborn observation for suspected condition, ruled out,” to categories P00-P04 has been deleted. A new Excludes1 note has been added to refer such cases to category Z05, Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out.

crivera0516

Paul I hear you, but the condition did exist. Bacteremia is a lab finding. The bacteria in the blood culture was real.The determination that it was a contaminant is from the type of bacteria found in the bottle.

evanspx@sutterhealth.org

No.  There is no  bacteria 'from the patient' that was growing in any blood.   This 'sounds' like a sampling error,  consequence of improper lab technique with skin contamination by tech or at time of draw?  This is not a valid finding.

morris-jeff@CooperHealth.edu

The contaminant most like was deemed normal skin flora from improper collection technique, but the patient did not have bacteremia or they would've been treated properly for it. They were suspected to have bacteremia on admission but the condition was ruled out.

evanspx@sutterhealth.org

http://errolozdalga.com/medicine/pages/skincontaminationbloodcultures.cr.5.29.11.html

evanspx@sutterhealth.org

Skin Contamination and Blood Cultures

There are really only four bugs that are commonly contaminants when blood cultures are positive:

1. Coag negative staph (gram positive cocci)
2. Corynebacterium (gram positive rods)
3. Propionibacterium acnes (anaerobic gram positive rods)
4. Bacillus species (anaerobic gram positive rods)

While these are commonly contaminants, be careful to rule out true infection in the following settings:

• When multiple blood cultures from different sets are positive
• When the patient has prosthetic devices

The following bugs are generally NOT skin contaminants are warrant further workup:

• Strep species
• Staph aureus
• Enterococcus
• Candida
• Pseudomonas and other Gram negative rods

crivera0516

 I am not disputing the contaminant. MD's do not know this when they admit and are required to treat. There is a cost for this treatment. Should this cost be less because the Bacteremia that was treated was a false positive?

katysuegood@gmail.com

It's fairly common that we have suspected conditions that require resources (radiologic studies, medication, etc), that then end up being ruled out.

We cannot code conditions that are no longer on the differential at discharge.

Katy

evanspx@sutterhealth.org

Bottom line is the coding must align with clinical reality.  Having said that,  I could list for days those clinical situations by which the payments seem unjust?  Have you ever considered your charges for severe sepsis (ICU) and considered the R.W.?  When a young woman that is pregnant is septic, why are we paid even less for managing her care as compared to a male of the same age?  

Paul Evans, RHIA, CCDS

morris-jeff@CooperHealth.edu

Off topic but since you brought up obstetrics Paul (lol)...it is very frustrating to have to sequence an "O" code as PDX on some of these pregnant patients who are very resource intensive. Trauma is very frustrating, especially those who should be in a MST DRG but end up in an OB DRG.

Ok, I am down off the soap box. Coding and the clinical reality are not congruent and that's something we all struggle with.

evanspx@sutterhealth.org

Jeff:   100% agree.  I have done thousands of OB cases and have always noted the R.W. for these is 'low' compared to other patient populations..it does seem 'unfair' given I'd think it more difficult to care for some of these women given the ARE gravid!   Your point is well-taken!  This is not about the coding, but about the RW assigned to the MS-DRGs for these patients.

morris-jeff@CooperHealth.edu

paul_evans_90314 said:

Jeff:   100% agree.  I have done thousands of OB cases and have always noted the R.W. for these is 'low' compared to other patient populations..it does seem 'unfair' given I'd think it more difficult to care for some of these women given the ARE gravid!   Your point is well-taken!  This is not about the coding, but about the RW assigned to the MS-DRGs for these patients.

Agreed, it's the RW...I wish no one was allowed to use MS-DRG's for OB, peds or neonates!

crivera0516

Love these discussions !!! TY everybody