Internal Medicine Coding Alert

Perceiving due to, benign could land you with incorrect Dx.

Be careful that your septicemia and hypertension savvy dont leak into your diagnostic code choice, or you could end up with an unsupported code. See if youre inferring too much with this quick quiz.

Urosepsis Is Synonymous With UTI

Question 1: A physician is treating a patient in the hospital and billing initial and subsequent care with documentation that contains only the term urosepsis.Should you code 038.9?

Answer 1: If there is no additional supporting documentation other than the term urosepsis, you should not use 038.9 (Unspecified septicemia), said Sandy Nicholson, MA, RHIA, CCS-P, in Establishing Medical Decision Making Level (MDM): Expert Secrets Revealed at The Coding Institutes National Coding and Reimbursement Conference in Orlando.

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.

ICD-9 confirms that without other supporting documentation, you have to code for UTI. The termurosepsis 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,according to the chapter specific guidelines.

When you look up sepsis in the ICD-9 manual,youre referred to 599.0 for urinary, as well as 995.91 meaning sepsis and 599.0 meaning urinary tract infection (UTI). Look at whether the physician documented that the patient has sepsis or a UTI.

If no other documentation exists, then according to rule, use 599.0. If documentation supports sepsis, then use 995.91.

Code 038.9 means the patient has septicemia, which could be due to a UTI. But you must see those words -- septicemia due to -- to use 038.9.

Either way, dont forget to code for the organism.Validate if an organism was cultured and from where (urine and/or blood).

Example: If E. Coli was cultured and the providers documentation supports sepsis, use 038.42 (E. Coli). If nothing was cultured, use 038.9.

Suppose the documentation supports only 599.0 and the urinary culture identified E. Coli. You will also need toreport 041.4.

Because septicemia is a severe presenting problem,038.9 can support a higher level of hospital care (such as 99223 and 99333) than 599.0 does, Nicholson points out.

Benign Is Not Inherent

Question 2: The only way a laundry-list note of chronic diseases and conditions describes hypertension is with HTN. Should you report 401.1 or 401.9?

Answer 2: You have to assign the fourth digit of 9 (401.9, Unspecified essential hypertension). To use 401.1 (Benign essential hypertension), the physician has to document something more, such as benign,

Nicholson says.

The real concern is whether you should list the hypertension diagnosis. You would list the diagnosis if the physician documents treating the condition or if the condition affects the treatment, notes Vicky Varley ONeil, CPC, CCS-P, owner of The Hazlett Group, a practice management consulting firm based in Birmingham, Ala.

ONeil recommends following these guidelines from ICD-9-CM Official Guidelines for Coding and Reporting effective Oct. 1, 2008:

" Chronic diseases: Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).

" Coexisting conditions: Code all conditions that coexist at the time of the encounter only if they affect patient care or management. Do not code conditions that were previously treated and no longer exist. You can,however, use history codes (V10-V19) as secondary codes if the historical condition or family history has an impact on current care or influences treatment.