Identifying Causative Organisms
To get to a more specific Sepsis code does the provider need to use linking terms between the organism and the diagnosis of sepsis (when there is only one identified infection present)?
Example of the provider's documentation:
Sepsis secondary to Pyelonephritis, present on admission, improving
-SIRS criteria met with Leukocytosis 13.6, febrile, tachycardic
-UA grossly positive
-CT abdomen demonstrating slight appearance that has been along the wall of the renal pelvises bilaterally as well as portions of the ureter suspicious for pyelonephritis
-Continue ceftriaxone
-Urine cultures positive E.coli sensitive to rocephin and cipro
Is the example above enough to link the E.coli to the Sepsis or is a query needed?
Comments
See AHA CC 1Q 2018 pg 16: Sepsis due to E coli UTI, assign A41.51, N39.0 and do not code B96.20 as the Sepsis specifies the organism.
Thank you for responding!
So, am I understanding the CC to mean I need to query the provider for more specificity from the documentation example above?
I would assign B96.20 as additional code if sepsis not linked with the E.coli - no query needed.
I see now with the documentation above it is not clearly linked, thank you for your response!