Mod03-Chapter1-Part2 sepsis 1

Documentation Dissection

Hospital Consultation Reason for Consultation: Sepsis |1| Assessment and Plan: The patient has peritonitis |2| and sepsis |3| with acute renal failure |4| and leukocytosis |5|. We plan to study him with a noncontrast CT scan now to evaluate for renal abscess, and bladder outlet obstruction. We will likely proceed after the noncontrast CT scan with exploratory laparotomy. We recommend continuing antibiotics resuscitation. _____________________________________________________________ |1| The patient is being seen for sepsis. |2| The patient also has peritonitis. |3| Sepsis is documented as a diagnosis. There is no documentation to support the organism causing the sepsis. |4| Acute renal failure is organ dysfunction which makes the sepsis considered severe sepsis. |5| Leukocytosis is an integral component of sepsis and is not reported separately. _____________________________________________________________ What ICD-10-CM code(s) is/are reported? ICD-10-CM Codes: A41.9, R65.20, N17.9, K65.9 Rationale: The patient has sepsis, peritonitis, acute renal failure and leukocytosis. Because the patient has organ dysfunction (acute renal failure), the sepsis is reported as severe sepsis (guideline Section I.C.1.d.1.a.iv.). Look in the ICD-10-CM Alphabetic Index for Sepsis/with/organ dysfunction (acute) (multiple) R65.20. In the Tabular List, subcategory R65.2 has notes for correct coding. First, there is a code first note to report the underlying infection first. Because we do not know the organism causing the infection, sepsis NOS (A41.9) is reported. Sepsis is found in the Alphabetic Index under Sepsis. The next note for subcategory R65.2 is to use an additional code to identify the specific acute organ dysfunction. Acute kidney failure is reported with N17.-. This is found in the Alphabetic Index by looking for failure/renal/acute N17.9. According to the sequencing guidelines Section I.C.1.d.3., A41.9, R65.20, N17.9, followed by the remaining diagnosis is the correct order. The patient also has peritonitis and leukocytosis. Look in the Alphabetic Index for Peritonitis K65.9. Leukocytosis is an integral component of sepsis and is not reported separately. Verify code selection in the Tabular List.

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