Suspicious, Probable, Likely Diagnoses

5/14/20 Progress note- Sepsis, suspicious of infective endocarditis.  Lactobacillus Bacteremia no clear evidence of vegetation.  TEE in AM.

 5/14/20 DC summary - Presented to the hospital for GNR+ blood cultures.  ID recommended TEE to further evaluate for endocarditis with vegetation or abscess on valves.  Cardiology unable to complete TEE d/t transfer to tertiary facility.Sepsis, Lactobacillus Bacteremia, Status post aortic valve replacement, S/P CABG, CAD

Do you think we should code or query the for Sepsis d/t suspicious infective endocarditis?


  • Sepsis is listed as a probable condition at discharge.  Coding rules state it is coded. If your team feels the condition lacks clinical support, perform Validation Query.  But, a condition listed as probable at the time of discharge is to be coded.  Hope this helps.

    Paul Evans, RHIA, CCDS
  • I am looking for the etiology of Sepsis, should the infective endocarditis be coded.  Progress note says it is suspicious and the DC summary states they could not perform the test to further evaluate.  Should we code it or query for it?

  • Technically, at the time of D/C, it is also stated as ‘suspicious’ and it should be coded.  The TEE was never completed and since the MD made the statement it probably existed at the time of D/C, it should be coded.  I thought you were earlier referring to Sepsis.  Personally, I am not sure what purpose a query would serve as the MD stated further testing was not able to be completed and presumably the condition was documented based on other factors.  (The MD can’t further make any determination based on what you have provided).
  • Also, (not trying to make this any more frustrating), but if this sepsis is associated with the valve that ‘has been replaced’, coding will assign a complication code as the PDX.  (Valve that has been replaced now infected and causing sepsis).
  • Thank you! You have answered my question, this really was confusing to me because " no clear evidence of vegetation.  TEE in AM." was documented on the progress notes.  Sometimes I think to hard on these things. 
  • Not sure how I helped, but glad to offer an opinion!
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