Q&A: Sequencing for sepsis and UTI
Q: What would be reported as the principal diagnosis if a patient was admitted with both a urinary tract infection (UTI) and sepsis? If the patient instead had a chronic Foley catheter and developed a catheter-associated UTI (CAUTI) with sepsis, would the CAUTI be the principal diagnosis or would it be the sepsis?
A: In the first instance, when the patient was admitted with a UTI and sepsis, sepsis would be the principal diagnosis as long as it was present on admission.
In the second instance, the ICD-10-CM complication code for the CAUTI (T83.511A [infection and inflammatory reaction due to indwelling urethral catheter, initial encounter]) would be the principal diagnosis, followed by the ICD-10-CM code for the sepsis. If the sepsis is identified as a complication related to an implanted device or medical intervention, the complication would always be sequenced first, followed by the sepsis.
Take a look at the fiscal year 2020 ICD-10-CM Official Guidelines for Coding and Reporting which state the following:
Sepsis due to a postprocedural infection
(a) Documentation of causal relationship.
As with all postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the infection and the procedure.
(b) Sepsis due to a postprocedural infection.
For infections following a procedure, a code from T81.40, to T81.43 Infection following a procedure, or a code from O86.00 to O86.03, Infection of obstetric surgical wound, that identifies the site of the infection should be coded first, if known. Assign an additional code for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04). Use an additional code to identify the infectious agent. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction. For infections following infusion, transfusion, therapeutic injection, or immunization, a code from subcategory T80.2, Infections following infusion, transfusion, and therapeutic injection, or code T88.0-, Infection following immunization, should be coded first, followed by the code for the specific infection. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned, with the additional codes(s) for any acute organ dysfunction.
(c) Postprocedural infection and postprocedural septic shock.
If a postprocedural infection has resulted in postprocedural septic shock, assign the codes indicated above for sepsis due to a postprocedural infection, followed by code T81.12-, Postprocedural septic shock. Do not assign code R65.21, Severe sepsis with septic shock. Additional code(s) should be assigned for any acute organ dysfunction.
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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