Thomas Posted Wed 22nd of May, 2013 14:28:00 PM
We did a consult on a patient with the diagnosis septic encephalopathy secondary to stump infection. I need to identify the organism. All notes indicate "polymicrobial infection" I am unable to find a diagnosis code. The best I came up with is 038.9 (generalized infect NEC, and I am not 100% on that. Any suggestions? Please and Thank you
SuperCoder Answered Tue 28th of May, 2013 19:34:55 PM
I also agree with you.
Urinary and sepsis issues may appear unrelated to the neurological conditions your practice is used to coding. However, a UTI can in fact lead to neurological problems in elderly patients.
A UTI means there are microorganisms, such as bacteria or fungus, in the patients urine.
When cultures grow out infectious agents which have spread through the body via the bloodstream, a physician might diagnose septicemia (038.9, Unspecified septicemia), bacteremia (790.7), or urosepsis (599.0, Urinary tract infection, site not specified; or 995.91, Sepsis). These are more serious medical conditions that require intravenous (IV) antibiotic and hospitalization for patients of any age, Lai says.
The infection will frequently cause encephalopathy with altered mental status and will aggravate any neurological condition the patient already has, Lai adds. This can cause weakness, confusion, agitation, somnolence, and other problems.