sepsis and organisms
Hi,
Need some help. CC 4th Qtr 1988 page 10 instructs to assign the specific septicemia code of the specified organism & the code for the local infection. Would it be appropriate to assign the specific septicemia code of the specified organism when blood cultures are negative and the body fluid culture is positive, and the physician describes his diagnosis as "Sepsis secondary to (localized infection)(with the specified organism)"?
For example: Septic Shock due to c-diff colitis; sepsis due to streptococcal pneumonia; or sepsis due e-coli uti
Your responses would be greatly appreciated.
Helga Reina, RHIT, CDIP, CCA, C-CDI
Documentation Improvement Specialist
Hunterdon Medical Center
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Need some help. CC 4th Qtr 1988 page 10 instructs to assign the specific septicemia code of the specified organism & the code for the local infection. Would it be appropriate to assign the specific septicemia code of the specified organism when blood cultures are negative and the body fluid culture is positive, and the physician describes his diagnosis as "Sepsis secondary to (localized infection)(with the specified organism)"?
For example: Septic Shock due to c-diff colitis; sepsis due to streptococcal pneumonia; or sepsis due e-coli uti
Your responses would be greatly appreciated.
Helga Reina, RHIT, CDIP, CCA, C-CDI
Documentation Improvement Specialist
Hunterdon Medical Center
Notice: The information contained in this email is intended only for the use of the person(s) identified above. This communication may contain work product which is privileged and confidential, and may contain content which is regulated by Federal law. If you are not an intended recipient or the employee or agent responsible to deliver this to the intended recipient, you have received this message in error and any review, distribution or copying of it by you is prohibited. If you have received this message in error, please notify the sender immediately, and delete the message. E-mail and communication system messages generated by members of the Hunterdon Healthcare workforce may not necessarily reflect the views of Hunterdon Healthcare, its officers, directors or management.
Comments
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Mary A Hosler MSN, RN
Clinical Documentation Specialist
Alumnus CCRN
McLaren Bay Region
1900 Columbus Ave.
Bay City, Michigan 48708
(989) 891-8072
mary.hosler@mclaren.org
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
Hi Paul and Mary,
Thanks for your response. That is the route I would take as well
because the clinician has made the link .
So for instance : "Sepsis due to e-coli UTI". Clinically the patient
has sepsis, urine cultures positive for e-coli, blood cx's neg , you
would use the following codes
03842 septicemia due to E coli
99591 sepsis
5990 UTI, site not specified
and NOT use the unspecified septicemia code 0389.
Helga Reina, RHIT, CDIP, CCA, C-CDI
Documentation Improvement Specialist
Hunterdon Medical Center
I use 038.9 too often, but prefer to use more precise codes, when possible.
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org