Home Health ICD-9/ICD-10 Alert

Published on Fri Jan 22, 2010 PDF

Question: Can I report 038.9 (Unspecified septicemia) for a patient with a diagnosis of "urosepsis?"

Answer: No, you should not use 038.9 (Unspecified septicemia) for "urosepsis." Urosepsis indicates a urinary tract infection (UTI). You should report 599.0 (Urinary tract infection, site not specified) for "urosepsis." According to ICD-9 guidelines, "The term urosepsis is a nonspecific term. If that is the only term documented then only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism if known."

Therefore, if the physician's documentation did not specifically include the term "sepsis, systemic inflammatory response syndrome, SIRS" or the causal organism, you would only report 599.0.

Best bet: When you see "urosepsis," go back and ask whether the patient has a simple UTI or sepsis due to UTI. If all you get back is urosepsis, then code the UTI.

Key point: Code 038.9 means the patient has septicemia, which could be due to a UTI. But you must see those words -- "septicemia due to" -- to use 038.9.

Another scenario: Suppose the physician described your patient's condition as urosepsis but the patient has organ failure due to sepsis. In this case, the UTI probably caused the sepsis which resulted in the organ failure of the patient. So, you would code the sepsis with the appropriate 038 code, followed by 995.92 (Severe sepsis) and then list the code for the specific organ failure.