This 73-year-old patient presented with fever. Blood cultures were positive for Candida albicans and the patient received antifungal therapy. In the final diagnostic statement, the provider listed sepsis due to urinary tract yeast (Candida) infection. She also had an obstructing kidney stone and hydronephrosis and a nephrostomy tube was placed prior to the current admission. Which would be the principal diagnosis, unspecified sepsis (038.9), disseminated candidiasis (112.5) or candidiasis of urogenital site (112.2)? Is code 995.91, Sepsis, appropriate as a secondary code assignment?
Assign code 112.5, Candidiasis, disseminated, as principal diagnosis. Disseminated candidiasis is a systemic (sepsis) infection. Codes 995.91, Sepsis; 112.2, Candidiasis, of other urogenital sites; 592.0, Calculus of kidney; 591, Hydronephrosis; and V44.6, Other artificial opening of urinary tract, should also be assigned as secondary diagnoses. Code 112.2 is assigned as an additional code to convey information about the nature of the urinary tract infection. There are no instructional notes in the classification that prohibit assigning codes 112.5 and 112.2 together. Category 038 is meant to classify bacterial infections; whereas candidiasis is a mycotic infection. Code 112.5 is the equivalent of code 038.9. The following reference can be found in the Official Guidelines for Coding and Reporting, “Sepsis and severe sepsis require a code for the systemic infection (038.xx, 112.5, etc.) and either code 995.91, Sepsis, or 995.92, Severe sepsis." This advice is similar to that previously published in Coding Clinic, Second Quarter 1989, page 10.