Internal Medicine Coding Alert

You won't find "urosepsis" terminology after October 2014.

If your physician notes the term "urosepsis" in a patient's chart, you may find yourself grappling with the question -- are you coding for a urinary tract infection (UTI) or a UTI with sepsis?

under ICD-9, that question doesn't hold as much bearing as in the future. Currently, you report 599.0 (Urinary tract infection, site not specified) for "urosepsis." According to ICD-9 guidelines, "The term urosepsis is a nonspecific term. If that is the only term documented then only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism if known."

Looking ahead: However, ICD-10 eliminates the term "urosepsis." The ICD-10 Manual includes a note to "code to condition," which means you must query the physician to determine the appropriate code assignment.

Specifically, ICD-10 guidelines state: (ii) Urosepsis. The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.

Action item: Explain to your physicians and coders that "urosepsis" does not exist in ICD-10. That means your physician should not use that term, unless he wants to be bothered with queries. More specific documentation about this condition is necessary.