Inpatient Facility Coding & Compliance Alert

Incorrectly coding sepsis in a hospital setting is easier than you might think, thanks to the range of terminology used to describe the condition. Take your first steps toward coding accuracy by understanding the difference between common terms – and how they differ from each other, despite how providers might document them.
Urosepsis is a catch-all term providers often use to describe both septicemia and a urinary tract infection. For accurate coding, determine which condition the patient has: sepsis or urinary tract infection. If you find documentation in the patient's record for both a diagnoses (urosepsis and septicemia), follow up with the physician to determine which diagnosis is more accurate.
ICD-10 prep: The term "urosepsis" does not exist in ICD-10. Guidelines for ICD-10 state:
(ii) Urosepsis  The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has [...]