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Monthly CDI Scenario Discussion – November 2019

Topic:  Fever of unknown origin


  • 65 year old male presented to the ED with a five-day history of increased congestion, cough, subjective fever, worsening lethargy, some confusion, weakness, and decreased oral intake.
  • In the ED, the patient was febrile 102.0 F, heart rate 90, BP 112/71,  RR18,  SPO2 94% on room air.
  • CT of head was negative. Blood work was significant for WBC 10.1, normal creatinine, normal lactic acid 1.4, negative procalcitonin, UA was unremarkable.
  • Patient was started on Rocephin and Zithromax in ED. He was admitted to a medical floor and was treated with IV antibiotics and continuous IV fluids 75 ml/hour.

Discharge summary:

  • Patient presented with Altered Mental Status, Cough, and Febrile Illness. Patient’s fever resolved with antibiotics. Pt had a negative head CT on admission. His infectious workup included blood cultures, sputum culture, Urinalysis, influenza PCR, Legionella and strep urine antigens which were all negative. He was treated with IV hydration, antibiotics, supportive care, and his mental status improved. His acute encephalopathy was attributed to an acute infection.
  • Discharge Medication List: azithromycin (ZITHROMAX) 500 MG tablets for 3 days.

Question:   Are there any query opportunities based on the scenario stated above?


Patient presented with fever with no known etiology noted. Fever resolved with IV antibiotics.

  • Fever is a symptom and usually has an underlying etiology
  • Fever can be due to a bacterial infection, viral infection, or other physiological factor

Patient presented with indicators of acute encephalopathy based on the information provided.

  • Acute Encephalopathy is characterized by alteration in brain function due to a systemic underlying cause usually resulting in altered mental status
  • Acute Encephalopathy is reversible and resolves when the underlying cause is correcte

UASI Recommends: 

  • Query for encephalopathy specificity: Unspecified encephalopathy is a CC whereas documentation of specificity (Metabolic) would add an MCC
  • Query for fever etiology is appropriate since the fever resolved after being treated with antibiotics and IV fluids
  • Coding signs and symptoms are a source of coding errors. A definitive diagnosis should be coded when it is known. If there is not a definitive diagnosis, then a query for clarification may be warranted
  • “Signs and symptoms are not to be used as principal diagnosis when a related definitive diagnosis has been established”

Documentation without clarification:

Principal diagnosis:     R509    Fever Unspecified

Secondary diagnosis:  G9340   Encephalopathy unspecified

DRG 864 Fever and inflammatory conditions   RW= 0.8474, GMLOS= 2.7, SOI/ROM 2/2

Documentation with clarification:

Principal Diagnosis: A499   Bacterial Infection, Unspecified

Secondary diagnosis: G93.41 Metabolic Encephalopathy     

DRG 867 Other Infectious & Parasitic Diseases Diagnosis with MCC RW=2.1852, GMLOS=5.5, SOI/ROM 2/1

CDI Educational Tips: 

The query choices are very important in this scenario since there is no clinical evidence noted in the medical record (e.g., all cultures negative). The physician’s response is solely based on his/her clinical judgment.

When writing a query for fever of unknown origin, query choices may include:

  • Fever due to unknown bacterial infection
  • Fever due to unknown viral infection
  • Other, please specify
  • Unable to determine/Unknown

If the query is asked at the time of discharge, the choices may include the words such as suspected, probable, or similar wording.

  • Fever due to suspected bacterial infection
  • Fever due to suspected viral infection
  • Other, please specify
  • Unable to determine/Unknown

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.