AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2019 Issue 3; Ask the Editor
Sepsis due to Multiple Possible Causes
A patient presents to the emergency department in severe respiratory distress due to possible aspiration. The patient was also noted to be septic on arrival due to pneumonia and Citrobacter urinary tract infection (UTI) associated with an indwelling suprapubic catheter. The patient was subsequently admitted, intubated and placed on a ventilator. The provider diagnosed sepsis due to catheter associated urinary tract infection (CAUTI), as well as due to “community acquired pneumonia due to aspiration.” Should sepsis due to a post procedural infection be sequenced first or should sepsis due to a localized infection be sequenced as the principal diagnosis, or is the aspiration pneumonia the principal diagnosis? ...
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Article Overview
This premium coding article addresses how to think about principal diagnosis assignment when sepsis is documented with multiple possible infectious sources. It is aimed at inpatient coders, CDI professionals, and coding educators who need guidance on broad sequencing considerations for complex sepsis scenarios involving respiratory and urinary sources and a postprocedural context.
Why This Topic Matters
Multifactorial sepsis cases often require careful review of the record to determine the condition chiefly responsible for the admission. Understanding the article helps readers evaluate similar inpatient cases without relying on assumptions about which infection source should drive sequencing.
What You Will Learn
- How the article frames principal diagnosis selection in complex sepsis admissions.
- What broad clinical and documentation factors are involved when more than one infection source is present.
- How the discussion relates sepsis sequencing to respiratory, urinary, and postprocedural infection contexts.
- How inpatient coding guidance is applied at a high level in multifactorial sepsis scenarios.
Who Should Read This
- Inpatient coders
- CDI specialists
- Coding educators
- Hospital reimbursement staff
- Clinical documentation reviewers
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