Q&A: ICD-10-CM sequencing for sepsis, UTI, pneumonia

Q: We recently had a patient who was admitted with sepsis and the physician documented sepsis, a urinary tract infection (UTI) related to a chronic Foley catheter, and pneumonia. Can we report sepsis first instead of the complication code, or is the complication always first?

A: My first stop is to go back and review the fiscal year 2020 ICD-10-CM Official Guidelines for Coding and Reporting. Section 2.G is why you’re asking the question. It states:

When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.

This guideline tells us that if the sepsis is related to the catheter-associated UTI (CAUTI), we need to sequence the sepsis first. But your situation is not that simple. The next guideline that can help us is Section 1.B.16, which says:

Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.

I am unable to view the provider’s exact documentation, but with the statement above, I am unsure if the provider identified the underlying cause of the sepsis. Was the sepsis linked to the pneumonia? Or the UTI? Blood cultures may assist in this determination.

If you follow the guidelines and send a query, my guess is that the provider will either say that he or she is unable to determine which contributed to the sepsis or both conditions apply, leaving you caught between a rock and a hard place. Additional considerations include:

• Were the UTI, pneumonia, and sepsis all present on admission?
• Was the UTI discovered incidentally (meaning a urinalysis was performed on the patient and supported the diagnosis of a CAUTI) when the patient’s presenting symptoms were respiratory related with the sepsis? Would the patient have been admitted for the CAUTI?
• Were there cultures obtained, and what were the results? Urinalysis? Sputum? Blood?

I love to have discussions like this with physicians. Clinically, they won’t see the point in clarifying, since the patient will be treated the same way no matter what. I take this opportunity to point out how important their documentation is in determining how the MS-DRG assignment and what “bucket” this patient will be placed in. This can have implications for the patient, the provider, and the organization related to reimbursement, outcome quality measures, and efficiency measures.

Remember, it’s important to not be leading in such a discussion but to ensure physicians understand why we ask the questions we do.

With all of this said, my thought is that the complication code should likely be sequenced first unless the provider specifically states that the sepsis is not related to the CAUTI.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director at HCPro in Middleton, Massachusetts, answered this question in the CDI Journal. Contact her at lprescott@hcpro.com.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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