Urosepsis

coder17

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If a patient is admitted with urosepsis due to streptococcus and there is an ammended to the record that states sepsis with streptococcus and uti due to to streptococcus is this the correct coding?

038.0;995.91;599.0;041.02

Thanks for any help!
 

mitchellde

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I am not seeing why you have appended the 041.02 it is not in the diagnosis statement.
Strep is the infection, sepsis is the systemic disease and the UTI is the localized infection dues to the the strep infection.
 

coder17

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Thank you Deb. I don't think I can code 599.0 with 995.91. I need to take out the 599.0, correct?
 

mitchellde

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No you code 3 codes one for the infection,(038.0) one for the systemic disease (995.91) and the 3rd for the local infection (599.0). Look in the coding guidelines in the sepsis section for coding a localized infection with sepsis.

Sreenivas Sajja-CPC,CCS: Thank You for the compliment, I have a lot of down time since my job requires that I travel so I am often in a hotel room or an airport with nothing to do :)
 
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Nancy Richardson RHIT, CPC

The correct answer to the question is to first query the physician as to what he means by "urosepsis."
ICD-9-CM assumes that "urosepsis" is a UTI, so the code for that term per se is 599.0.
However, the term is ambiguous because most physicians use it to mean general sepsis arising from a UTI. In my hospital, our coding supervisors and documentation improvement specialists continually discourage our attendings from using the term "urosepsis" at all. When we coders see it, we are obliged to query.
Deb's sepsis codes are correct, but the original documentation needs to be clarified first. And yes, the 041 code is not needed because the 038's are combination codes that identify both the sepsis state and the responsible organism.
 
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