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UTI, Sepsis coding help

  1. #1
    Default UTI, Sepsis coding help
    Medical Coding Books
    I have a patient that the providers give a dx. of UTI, Sepsis, acute renal failure, the blood culture came back with a growth of enterococcus faecalis. But on the lab it does not state septicemia. Can not code Sepsis with out a infection process from the 038.x category. Any suggestions on the ICD 9 dx code to use?

  2. #2
    Columbia, MO
    The ICD-9 guidelines have you covered on this one.
    Sepsis and severe sepsis require a code for the systemic infection (038.xx, 112.5, etc.) and either code 995.91, Sepsis, or 995.92, Severe sepsis. If the causal organism is not documented, assign code 038.9, Unspecified septicemia.

    also remember that a coder may not code results froma lab report, the physician would have to document that in the progress notes, but the guidelines will allow you to use 038.9 when the physician documents sepsis.

    Debra A. Mitchell, MSPH, CPC-H

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