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Rebeka Posted 4 Year(s) ago

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 Posted 4 Year(s) ago

Hi,

We are working on it .

Thanks,

SuperCoder Posted 4 Year(s) ago

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.

Posted by Rebeka, 4 Year(s). There are 3 posts. The latest reply is from SuperCoder.

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