EmailAcute renal failure secondary to E.Coli Sepsis
Publication Date: March 2011
Implementation Date: 1/07/2020
ICD 10 AM Edition: Seventh edition
Query Number: 2573
Patient diagnosis on discharge summary states Acute renal failure secondary to E.Coli Sepsis.
There is no documentation in notes of severity of sepsis, ie SIRS, septic shock or severe sepsis.
In the body of the progress notes pneumonia is documented, as well as E.Coli Sepsis ?source biliary disease. Also acute renal failure/hepatic failure secondary ?sepsis. No documentation of pneumonia on the discharge summary. As it is unclear what the localised infection is do we code A41.51 as PDx (E.Coli Sepsis) followed by pneumonia and the organ failures?
There is no documentation in notes of severity of sepsis, ie SIRS, septic shock or severe sepsis.
In the body of the progress notes pneumonia is documented, as well as E.Coli Sepsis ?source biliary disease. Also acute renal failure/hepatic failure secondary ?sepsis. No documentation of pneumonia on the discharge summary. As it is unclear what the localised infection is do we code A41.51 as PDx (E.Coli Sepsis) followed by pneumonia and the organ failures?
Response
This query was originally published in March 2011 and previously retired on 30 June 2010. It was reinstated effective 1 July 2020 following a review as the advice is considered current.
With regard to the code for sepsis, review of the progress notes showed no documentation providing the source of the infection. Therefore in accordance with ACS 0110 Sepsis, severe sepsis and septic shock assign a code for sepsis by searching the index under lead term Sepsis, which in this case is A41.51 Sepsis due to Escherichia coli [E. Coli].
Pneumonia and organ failure must meet criteria for coding in order to be coded.
As the diagnosis on the discharge summary is ARF secondary to sepsis, one of these conditions will be the principal diagnosis and a decision must be made accordingly based on ACS 0001 Principal diagnosis.
With regard to the code for sepsis, review of the progress notes showed no documentation providing the source of the infection. Therefore in accordance with ACS 0110 Sepsis, severe sepsis and septic shock assign a code for sepsis by searching the index under lead term Sepsis, which in this case is A41.51 Sepsis due to Escherichia coli [E. Coli].
Pneumonia and organ failure must meet criteria for coding in order to be coded.
As the diagnosis on the discharge summary is ARF secondary to sepsis, one of these conditions will be the principal diagnosis and a decision must be made accordingly based on ACS 0001 Principal diagnosis.
