Principal Diagnosis Sepsis or Superior vena cava occlusion

QUESTION WHICH SHOULD BE PRINCIPAL - both conditions POA, sent d/t sepsis  but also had other condition treated.

Patient past hx of ESRD on HD MWF, HTN/HLD, RA, TIA, hyperparathyroidism, DM type II, hx of chronic DVT

admitted for sepsis likely 2/2 LUE cellulitis with calciphylaxis. (Aggregation of calcium in blood vessels of the fatty tissue and skin.)
WBC 12.7*
BP 80/73
RR 21
HR 79 - 82

Was planning for fistulogram and biopsy of lesions tomorrow in OR. Pt was admitted for hypotensive after HD today.

Nephrology reports: concurrently a catheter as her dialysis access in the right internal jugular vein proceeding into the superior vena cava. She also had a superior vena cava occlusion. 

1. Calciphylaxis left arm.
2. Superior vena cava occlusion.
1. Fistulogram.
2. Central venogram with PTA of the superior vena cava with 14 x 4
3. Left arm skin lesion biopsy for permanent section and culture.

Flow going through the superior vena cava appeared to be occluded
This was angioplastied up to 4 atmospheres and opened up the lesion very nicely.

Please let me know which would/should be Principal and why.   
Thanks for your time and expertise!


  • The sepsis should be principal based on the coding guidelines.

    Official Coding guidelines FY 2020 Section I.C.d.3 Sequencing of severe sepsis, states: "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."
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