Home Health ICD-9/ICD-10 Alert

Stick with UTI, drop diabetes code.

Question 1: Among your new admission's documented diagnoses is "urosepsis." The patient is still on antibiotics. Should you code 038.9 (Unspecified septicemia) for urosepsis?

Answer: No, said Sandy Nicholson, MA, RHIA, CCS-P, in "Establishing Medical Decision Making Level (MDM): Expert Secrets Revealed" at The Coding Institute's National Coding and Reimbursement Conference in Orlando.

038.9 is not the code to use for "urosepsis." That term means a urinary tract infection (UTI).

You instead have to use 599.0 (Urinary tract infection, site not specified) for "urosepsis." Look up this term in the ICD-9 manual and you'll find 599.0.

Action: When you see "urosepsis," go back and ask the physician if he is treating a simple UTI or sepsis due to UTI, Nicholson advises. If all he says is "urosepsis," then code the UTI.

Question: An elderly woman requires treatment for a documented diagnosis of "Charcot foot." You know the main cause of the condition in the United States is uncontrolled type II diabetes. Can you code 250.60 (Diabetes with neurological manifestations; type II or unspecified type, not stated as uncontrolled) and 713.5 (Arthropathy associated with neurological disorders)?

Answer: Unless the documentation specifies "Charcot foot due to diabetes," you have to code the general reason for Charcot foot, which is tertiary syphilis (094.X), Nicholson said.