Wiki Code First note

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midnightsun1369

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Hello,

If a dx has a code first note but none of the code first dx's listed apply to the pt can this dx still be used?

ex: sepsis A41 other sepsis states code first
postprocedural streptococcal sepsis
streptococcal sepsis during labor
streptococcal sepsis following abortion
etc, etc.

none of above apply to pt, so I'm confused?
 
Code First, Unspecified

I would use A41.9, Sepsis, NOS (unspecified organisim - unless you know organism). When indexed, states "Sepsis (generalized) (Unspecified organism)" (A41.9) Hope that helps!
 
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this is what the note states under his dx listings. no documentation of any of the listed code first dx.

CV: sepsis with hypotension-suspect urinary source, but potenitally chronic decub ulcer
- no hx CAD
- Cont vanc and meropenem
- Start LR, cont to monitor CVP prn
- off levo 12/7
- pending blood culture and urine cultures- negative
 
Guidelines state:
For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism.
 
According to this guideline that would be correct:
Code first” notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a “code first” note and an underlying condition is present, the underlying condition should be sequenced first.

So since you have no stated underlying condition the you may code the A41.9 first.
 
Sepsis-Acute Organ Dysfunction

I just wanted clarity for SEPSIS coding when it pertains to acute organ dysfunction. When billing for SEPSIS with acute respiratory failure. Would the following be correct:

According to the coding guidelines acute organ dysfunction should be dealt with by following the "sever sepsis guidelines"
In Severe Sepsis 2 codes must be used indicating the code for the organ dysfunction.

1. J96.00
2. R65.2

Would this be correct or should A41.9 also be used?

New to SEPSIS coding trying to understand I follow the guidelines. Thanks in advance
 
pashirley said:
I just wanted clarity for SEPSIS coding when it pertains to acute organ dysfunction. When billing for SEPSIS with acute respiratory failure. Would the following be correct:

According to the coding guidelines acute organ dysfunction should be dealt with by following the "sever sepsis guidelines"
In Severe Sepsis 2 codes must be used indicating the code for the organ dysfunction.

1. J96.00
2. R65.2

Would this be correct or should A41.9 also be used?

New to SEPSIS coding trying to understand I follow the guidelines. Thanks in advance
Click to expand...


code A41.9 as principal followed by J96.00 and R65.20
 
The coding guidelines state:
The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. Additional code(s) for the associated acute organ dysfunction are also required.
If you have the underlying infection documented you would code that along with any organsim and not the A41.9.
 
Sepsis- Acute Organ Dysfunction

Thank you for the clarification. I did look up the coding guidelines and wanted to see where the specifics were in regards to the A41.9. Thanks
 
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