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pneumonia and sepsis

Rebeka Posted Sun 15th of December, 2013 18:46:17 PM

If a patient is admitted with fever, lethargy, productive cough, shortness of breath and altered mental status. In the h&p it says pneumonia with hypoxia and possible early sepsis. the final diagnosis is pneumonia with early sepsis. Would the primary code be 486 and secondary be 995.91..Should I code for the shortness of breath etc? What would the DRG be?

SuperCoder Answered Mon 16th of December, 2013 08:39:52 AM


We are working on it .


SuperCoder Answered Tue 17th of December, 2013 13:21:26 PM

The selection of Sepsis as the principal diagnosis will depend upon the clinical presentation and diagnosis of sepsis by the physician.Sepsis can only be reported as principal Dx. when the POA status of this diagnosis is "Y". If there is documentation of sepsis in the medical record, then you are advised to follow the sepsis reporting guidelines :
In the presented scenario you should assign codes: 038.9, 486, 995.91
DRG for the presented scenario would be: 872.

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