H&P: An 82-year-old female was transferred from a skilled nursing facility with reported high fever, and AMS; temp up to 101.4 at the nursing home; patient has chronic indwelling Foley catheter with history of neurogenic bladder; per nursing home report catheter was last changed 4 weeks prior.
PMH: Diabetes type 2, neurogenic bladder, hx of frequent UTI’s, Alzheimer’s Dementia with baseline of orientated to time and place.
Vitals: HR 115, RR 24, Temp 101.5, B/P 110/70
Labs: WBC 16, Lactic Acid 3.6; urinalysis + for WBC. leukocyte esterase, nitrites and 4+ bacteria; urine cx + for E. coli
PE: Obtunded, disoriented x3; Indwelling catheter with foul cloudy urine
Treatment: Foley catheter changed on admission; 1:1 safety companion due to AMS
Medications Ordered: Rocephin 1 Gm IV daily, vancomycin 500 mg IV daily, NS 1-liter bolus x 2, sliding scale insulin, Aricept 10 mg PO daily
Discharge Summary: Patient transferred from SNF due to AMS and high fever. Found to have Sepsis due to UTI. Foley exchanged, fluid resuscitated and antibiotics administered. Orientation back to baseline of orientated to time and place, WBC count WNL, lactic acid level back down to normal and fever free for >48 hours. Rx of Bactrim given on DS. Final diagnosis: Sepsis due to UTI, AMS due to Sepsis
Question: Are there query opportunities based on the scenario stated above?
Discussion: The patient exhibited the following risk factors and clinical indicators:
- Chronic indwelling Foley catheter
- History of neurogenic bladder and frequent UTI’s
- Documentation by the attending of sepsis due to UTI
- Elevated WBC of 16, lactic acid of 3.6 with a + U/A and Urine Cx
- Treatment included: Foley change on admission, broad spectrum antibiotics, 1:1 safety companion and IV fluids
- Query for UTI related to chronic indwelling Foley catheter.
- Query for Acute Metabolic Encephalopathy, including if related to sepsis as acute organ dysfunction
- Query for Lactic Acidosis, including if related to sepsis as acute organ dysfunction
Documentation without Clarification:
- Principal Diagnosis: Sepsis with E. coli (A41.51)
- Secondary Diagnosis: UTI (N39.0), Altered Mental Status (R41.82), Neurogenic Bladder (N31.9), Diabetes Mellitus Type 2 (E11.8), Alzheimer’s Dementia (G30.9)
- Working DRG: 872: Septicemia or sever sepsis w/o MV w/o MCC
- RW: 1.0263 SOI/ROM: 2/2
Documentation with Clarification:
- Principal Diagnosis: Infection due to Urinary Catheter, Initial Encounter (T83.518A)
- Secondary Diagnosis: Sepsis with E. coli (A41.51), Metabolic Encephalopathy (G93.41), Acidosis (E872), Severe sepsis without septic shock (R65.20), UTI (N39.0), Altered Mental Status (R41.82), Neurogenic Bladder (N31.9), Diabetes Mellitus Type 2 (E11.8), Alzheimer’s Dementia (G30.9)
- Working DRG: 698: Other kidney and urinary tract diagnosis with MCC
- RW: 1.6106 SOI/ROM: 4/3
CDI Educational Tips:
- Review ER notes or transfer notes carefully for the presence of a catheter on admission, or history of patient intermittently self-catheterizing. If POA status is not clear, query as this will impact sequencing.
- Review for the organism related to the UTI.
- Query the physician if urosepsis is documented. Urosepsis is a nonspecific term and is not indexed in ICD-10, therefore requires clarification.
- Patients with devices, implants, or grafts often develop sepsis due to the presence of the device. A cause and effect relationship cannot be assumed and must be documented by the physician. If this link is not made, or there is conflicting documentation, a query is necessary to clarify the cause and effect relationship.
Pertinent Coding References:
Official Guidelines for Coding and Reporting, Section I.C.d.5.b:
Sepsis due to a post procedural infection. For such cases, the post procedural infection code, such as T80.2, Infections following infusion, transfusion, and therapeutic injection, T81.4, Infection following a procedure, T88.0, Infection following immunization, or O86.0, Infection of obstetric surgical wound, should be coded first, followed by the code for the specific infection.
Severe Sepsis and Acute Organ Dysfunction/Failure, Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017; Page 98
Code assignment is based on the provider’s documentation, the instructions in the classification, as well as the current coding guidelines.
The Official Guidelines for Coding and Reporting must be followed. Section I, C, 1, d, 1, a, (iii) of the guidelines states that a code is assigned for severe sepsis, when the provider documents sepsis and an associated acute organ dysfunction or multiple organ dysfunction. It is also appropriate to assign a code for severe sepsis when the provider documents “severe sepsis,” or when the Index to Diseases directs the coder to the code for “severe sepsis.”
The conditions that represent an acute organ dysfunction in severe sepsis which are listed under subcategory R65.2-, Severe sepsis, is not an exhaustive list. Therefore, if the documentation is unclear regarding whether a specific condition is considered organ dysfunction/failure, query the physician for clarification, since this is a clinical question.
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.