Neurology & Pain Management Coding Alert

Question: At the request of an urologist, our neurologist consulted on an inpatient with altered mental status. The patient has urosepsis due to a urinary tract infection, an infection at the site of a ventriculoperitoneal (VP) shunt with suspected cellulitis, and a history of traumatic brain injury. Some of these conditions are out of the ordinary for us. How should I code them?

Michigan Subscriber

Answer: The primary diagnosis is 780.97 (Altered mental status). Your secondary diagnosis will be 996.63 (Infection and inflammatory reaction due to internal prosthetic device, implant and graft; due to nervous system device, implant and graft). This code would not be linked as primary for your neurologist's inpatient visit as this is not the condition that is chiefly responsible for your physician's E/M services. However, it is a co-existing condition that affects the patient's care.

You'll also list V15.52 (History of traumatic brain injury) for the late effects of traumatic brain injury.

According to ICD-9 guidelines, "Either the term sepsis or SIRS must be documented to assign a code from subcategory 995.9 ... 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."

In your case, if the physician's documentation did not specifically include the term "sepsis or SIRS" or the causal organism, you would only report 599.0 (Urinary tract infection, site not specified).