Neurology & Pain Management Coding Alert

Question: Our neurologist completed a consult on a patient with the diagnosis septic encephalopathy secondary to stump infection. I need to identify the organism. All notes indicate “polymicrobial infection,” but I am unable to find a diagnosis code. The best I came up with is 038.9, but I’m not sure it’s correct. Any suggestions?

New Mexico Subscriber

Answer: Urinary and sepsis issues may appear unrelated to the neurological conditions your practice normally codes, but a UTI (urinary tract infection) actually can lead to neurological problems in elderly patients. For example, the infection will frequently cause encephalopathy with altered mental status and will aggravate any neurological condition the patient already has. This can cause weakness, confusion, agitation, somnolence, and other problems.

Septic encephalopathy (SE) or sepsis-associated delirium is the most common encephalopathy in ICU patients. It is defined by brain dysfunction due to systemic inflammatory response syndrome (SIRS) and extracranial infection. Clinically, acute impairment in level of consciousness and confusion are primarily defining symptoms. The ICD-9 code for septic encephalopathy is 348.31 (Metabolic encephalopathy) which also includes septic encephalopathy.

In order to compliantly code the patient’s condition with ICD-9 codes, ask the physician whether the patient does have SIRS. The HIPAA mandated ICD-9 guidelines include specific directions in reporting SIRS. See Section I.C.1.b. for the specific guidelines including sequencing primary and secondary diagnosis code order and if the sepsis is due to post-procedural infection.

As for the polymicrobial infection, the term “polymicrobial” is defined as marked by the presence of several species of microorganisms. If no further specification is indicated in the patient’s record, lab culture reports, etc. then the 038.9 (Unspecified septicemia) ICD-9 code would be appropriate to report for this unspecified causation.

Report the stump source of the infection with 997.62 (Infection [chronic] of amputation stump) unless it is clearly documented to be due to a post-procedural infection. In that case, you would report 998.59 (Other postoperative infection).