Wiki Sepsis-Cholecystitis

[pashirley]

Can you please provide some direction on coding Sepsis due to cholecysitis. How many codes are necessary and the sequencing.

 

[pashirley]

Sepsis-Cholecysitis

I wanted to provide the below information. If someone can take a look and tell me if they feel it is coded correctly

Sepsis with acute Cholecystitis:

Coding GUIDELINES (Page 7): (a) Sepsis For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism. A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented.

(iii)Sepsis with organ dysfunction If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction (MOD), follow the instructions for coding severe sepsis.

Coding GUIDELINES for Severe Sepsis (Page 7)

Severe sepsis The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. Additional code(s) for the associated acute organ dysfunction are also required

Sepsis with Acute Organ Dysfunction Coding

1. Follow the guidelines for severe sepsis
2. Severe sepsis requires at the minimum 2 codes (the acute organ dysfunction and R65.20 for the severe sepsis)
3. A41.9 should be coded as primary when there is no underlying systemic infection listed.

1. A41.9 (No underlying systemic infection noted)
Sepsis, unspecified organism
Septicemia NOS

2. K81.0: Acute Cholecystitis (Acute Organ dysfunction)

3. R65.20: Severe sepsis without septic shock Severe sepsis NOS