"Septic shock due to E Coli bacteremia", can you code E Coli sepsis based off this documentation?

cmhteam

Hi everyone, 

A discussion came up with my team regarding documentation of 'septic shock due to E Coli bacteremia', present on admission. The septic shock is clinically validated throughout the record with organ dysfunctions noted. The word "sepsis" was not stated separately anywhere; only "septic shock due to e coli bacteremia" is documented throughout the record.

Sepsis is the principle diagnosis in this case since POA. Would you take E Coli sepsis as the principle diagnosis? Or, do you think a query is needed to have E Coli sepsis specifically documented? Bacteremia is currently listed as the pdx, but from a CDI standpoint, I believe the above statement clearly shows that sepsis is due to e coli bacteremia. Even though sepsis alone isn't stated, septic shock is and you can't have septic shock without sepsis. It's just a little confusing on whether to assume or clarify since the E Coli sepsis is it's own code and septic shock is it's own code. 

Would love to hear others input on this topic, thanks!

Borgonyt

Coding guidelines direct us to code sepsis as PDX when septic shock is diagnosed and documented. it is correct to reason that to have septic shock there must be the presence of sepsis. So septic shock should never be a PDX. If documentation states the E. Coli (organism) bacteremia (blood infection) is the cause of the septic shock (sepsis), then there is no reason to query for organism specific sepsis as it is already clear.
Bacteremia should not be used as a PDX. The PDX should be the "acute" condition the bacteremia "manifested" and prompted the patient to come to the hospital. If bacteremia is present, it should be assigned as a secondary diagnosis as long as it meets the criteria for the definition of a secondary diagnosis.

cmhteam

Thank you, this helps confirm our process. Do you have a direct reference to the coding guidelines you are referring to on this topic? I know when sepsis is POA it is supposed to be the pdx, but do you the reference to the coding guideline re: code sepsis as PDX when septic shock is diagnosed and documented?

Thanks again!

morris-jeff@CooperHealth.edu

Septic shock is a manifestation code and should not be sequenced as the PDX.

From the Official Coding Guidelines

Septic shock (a) Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction. For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Postprocedural septic shock. Any additional codes for the other acute organ dysfunctions should also be assigned. As noted in the sequencing instructions in the Tabular List, the code for septic shock cannot be assigned as a principal diagnosis. 3) Sequencing of severe sepsis If severe sepsis is present on admission, and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List. A code from subcategory R65.2 can never be assigned as a principal diagnosis. When severe sepsis develops during an encounter (it was not present on admission), the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as secondary diagnoses.