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Cardiology Coding:

Pay Attention to Septic Embolism Code First Notes

Question: A cardiologist at my practice documented that a patient with infective endocarditis developed a septic embolism in the left upper extremity. The provider recorded treatment plans specifically for the septic embolism. Do I report the septic arterial embolism as the principal diagnosis?

Maryland Subscriber

Answer: Remember, when reporting sepsis, you usually don’t report the sepsis code first, because sepsis is often a manifestation of another condition.

In fact, when you look at the ICD-10-CM Coding Guidelines notes for septic embolism codes, you’ll see that coders are instructed to “Code first underlying infection.” In this case, the provider documents that the patient has infective endocarditis.

Accordingly, you should report these diagnosis codes in this sequence:

  • I33.0 (Acute and subacute infective endocarditis)
  • I76 (Septic arterial embolism)
  • I74.2 (Embolism and thrombosis of arteries of the upper extremities).

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAP

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