It can be helpful for the MD to cite the source of the sepsis, such as PNA, UTI, etc. In particular, the cause of the sepsis impacts the assigned DRG as the principal Diagnosis 2/2 to an infected device or postop infection will yield different DRGs and billing than sepsis 2/2 something such as PNA, cellulitis. It is also important to cite source of sepsis as this source may be an MCC, such as w/ PNA. Also note that not all sepsis is bacterial and that sepsis can be classified to a multitude of organisms as the etiology. However, as identification of etiology not always feasible, it is permissible to simply code 'sepsis' as 'cause not known'.
Comments
It can be helpful for the MD to cite the source of the sepsis, such as PNA, UTI, etc. In particular, the cause of the sepsis impacts the assigned DRG as the principal Diagnosis 2/2 to an infected device or postop infection will yield different DRGs and billing than sepsis 2/2 something such as PNA, cellulitis. It is also important to cite source of sepsis as this source may be an MCC, such as w/ PNA. Also note that not all sepsis is bacterial and that sepsis can be classified to a multitude of organisms as the etiology. However, as identification of etiology not always feasible, it is permissible to simply code 'sepsis' as 'cause not known'.
Paul Evans, RHIA, CCDS