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?
When determining the principal diagnosis for a patient with multifactorial sepsis, the principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction, any one of the diagnoses may be sequenced first.