Melissa Posted Thu 25th of July, 2013 13:42:59 PM
dx 1 febrile neutropenia
2 septic shock
3 R LL pneumonia
5 myasthenia gravis
Septic shock quidelines require an organ failure there is not one documented and I ask the physicain he said there is not one ase well?
Do I not code the septic shock or do I code just sepsis 99591 even though thats not what the guidelines state?
SuperCoder Answered Mon 29th of July, 2013 10:01:57 AM
Septic shock guidelines state:
For all cases of septic shock, the code for systemic infection should be sequenced first, followed by codes 995.92 & 785.52. Any additional codes for other acute organ dysfunctions should also be assigned. The code for Septic shock cannot be assigned as a principal Dx.
Now, the notes below the code 785.52, at tabular section of ICD-9 says:
Use additional code, if applicable, to identify SIRS due to infectious process with organ dysfunction (995.92).
And finally, the Notes below to code 995.92, at tabular section of ICD-9 suggests:
Use additional code to specify acute organ dysfunction, such as:
septic shock (785.52)
So even if any organ dysfunction has not taken place, you should still be able to bill SEPTIC SHOCK with:
infection code (if nothing, then 038.9), 995.52, 785.52
Also bill other Dx codes keeping in mind the primary Dx code and "present on admission" condition. If not clear from the documentation, plz enquire the physician about it.