Melissa Posted Mon 03rd of June, 2013 16:32:09 PM
here is the note sepsis suspet GU source. PT had E coli found in urine and in blood. so here is the question I know I code the ecoli
038.42 then the sepsis
995.91 and then the uti
599.0 do I code the bacteremia?
SuperCoder Answered Tue 04th of June, 2013 20:08:35 PM
Bacteremia - Presence of bacteria in the blood, as confirmed by a positive blood culture. The condition may occur after a surgical procedure, labor, or teeth cleaning, and according to Coding Clinic 2000, "progresses to septicemia only when there is a more severe infectious process or an impaired immune system."
Make sure you code it as a lab finding only (790.7, Bacteremia), because you need more information from the physician to determine its clinical significance. Of note, this type of specific information is rarely available in the ED when the patient first presents.
Keep in mind, says Coding Clinic for fourth quarter 2003, that bacteremia is not just defined by the presence of bacteria in the blood, but by "bacteria in the blood without an associated inflammatory response."
Melissa Posted Wed 05th of June, 2013 12:54:03 PM
That really didnt answer my question.
SuperCoder Answered Thu 06th of June, 2013 00:40:50 AM
Bacteremia is sometimes used interchangeably with the clinical term of sepsis by physicians. To answer your question, let's take a look at the interrelationship of the clinical entities in the case of a patient admitted with a documented urinary tract infection, blood cultures that grow positive for E. Coli and documented SIRS.
This patient was admitted with a urinary tract infection and what was described as a clinical evidence of sepsis, that is elevated temperature, shaking chills, rigor, elevated white blood count with a left shift and altered mental status. In order of decreasing frequency, the etiologies of sepsis are UTI, respiratory, gastrointestinal and integumentary system. Additionally, the patient developed positive blood cultures, described as bacteremia by the physician. The diagnosis of bacteremia is problematic in that bacteremia by definition is bacteria in the blood, nothing more, nothing less. The physician did not indicate the significance of the positive blood culture except to state "bacteremia." The term bacteremia is considered an abnormal laboratory value and hence explains why it is classified under ICD-9 classification to signs, symptoms and ill-defined conditions. In general, the physician should not be using the terminology of "bacteremia" if there is suspected or presumed clinical significance of the bacteremia. The clinical significance of the positive blood cultures should be well described and explicitly documented by the physician, such as positive blood cultures from an ischemic, ruptured bowel, positive blood cultures from a ruptured appendix, positive blood cultures from a urinary tract infection, positive blood cultures from a seeded valve and so forth and so on.
Without further qualification from the physician, you should not assign the bacteremia as the principal diagnosis in this case. As you point out, SIRS or systemic inflammatory response syndrome is discussed in the 2nd quarter 2000 Coding Clinic. In this Coding Clinic, SIRS is described as a clinical response to an insult, infection, or trauma, that includes systemic inflammation, elevated or reduced temperature, rapid heart rate and respiration and elevated white blood count. The medical community recognizes SIRS as a major complication of infection or trauma. For patients admitted with septicemia, the symptoms of SIRS are generally present. This same Coding Clinic goes on to point out that while there are no sequencing restrictions on the SIRS codes, generally they will be listed as secondary codes. The principal diagnosis should be the infection or the trauma that brought the patient in.
Getting back to your case, the principal diagnosis should be UTI with secondaries of SIRS and bacteremia, in light of the incomplete documentation by the physician. A better alternative is to seek clinical clarification from the physician, attempting to identify the clinical significance of the patient's positive blood cultures and bacteremia and its relationship to the UTI and the SIRS. If anything, capitalize upon the opportunity to use this case as a "teaching tool" for the physician, making the point that sepsis and bacteremia are not clinical entities of the same nature.