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  1. Question Sepsis
    Medical Coding Books
    This is a subject that I find is the most difficult to code for. The physician admitts a paitent in the hospital and has diagnosed the patient with sepsis due to UTI or Pneumonia etc. The patient may have acute kidney failure or acute respirtory failure due to this also. He will document after a couple of days that the patient sepsis has resolved but the patient is still on an antibiotic and we are still monitoring the organ failures. Do I continue to code this as sepsis "038.9, 599.0 or 486, and 995.91 or 995.92 " all through the hospital stay and should I talk with the physician to inform him that as this is what the primary reason the patient was admitted for and as long as we are treating this problem all through the hospital stay he should continue to document this as such?

  2. #2
    Coastal Coders
    I think in this case talk to the doctor about documentation because you must code the systemic infection first, then 995.91 or 995.92, plus a code for the organ failure if that is the case and you have to have documentation that the organ failure is due to the sepsis.

  3. #3
    Columbia, MO
    the infection is the septicemia 038.9 the systemic disease is 995.91 or 92 and the localized infection due to the sepsis is the 486 or the 599.0.. in the coding guidelines it is coded in that order with any organ failure listed last.

    Debra A. Mitchell, MSPH, CPC-H

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