Hi everyone, how are you today? Welcome back and if you are new here, welcome to my channel where you can learn the real-world coding experience and this is Hoang, the coding expert. If you want to pass coding exam to start your coding career or if you are already holding a coding credential, working in the field and want to learn more in order to advance your coding profession, then you are in the right place. It has been a while since I posted the last video, so I hope you all had a relaxing and enjoyable summer with your friends and family.
It's hard to believe we are about to start a month of September already, and school will be starting again in a few weeks. September is a popular time to set goals for your personal development, your career advancement, and renew motivation. earning a coding credential is the most important stepping stone to a career in medical coding. And if you are a new student, then passing the coding exam will be your first goal this fall.
For those of you who already passed the CPC, COC or CCA exam, then I will bring your coding skill to the next level, getting you ready for the CCA exam or other specialty exams. But in order for me to do that, I will need your full support. Today's topic is how to cause sepsis, severe sepsis and septic shock.
It can be very challenging and confusing for you to code a record with a sepsis diagnosis without knowing its disease process and the sepsis coding guidelines and I'm here to help. Alright, without further ado, let's get started. Terms to know Coding a record with a sepsis or septicemia diagnosis can be very challenging, especially if you are new to coding or have never coded an inpatient record before.
In addition, The physicians may use the term sepsis, septicemia, severe sepsis, or such interchangeably, so I just wanted to make sure that, first, you understand the definition of these terms, and then each disease process. Bacteremia is the presence of bacteria in the bloodstream after a trauma or an infection. Sepsis is the body's deadly response to an infection.
Septicemia is a systemic disease associated with pathological microorganisms or toxins in the bloodstream. SIRS stands for systemic inflammatory response syndrome. A systemic response to infection or trauma with such symptoms as fever, rapid heart rate, tachycardia. and elevate white blood cell count.
Severe sepsis is defined as such due to an infection that progresses to organ dysfunction or failure such as kidney or heart failure. And last, septic shock generally refers to circulatory failure associated with severe septic and therefore it also represents a type of acute organ dysfunction. Sepsis spectrum.
You already know the definition of those common terms that are related to sepsis or septicemia. And now I want you to understand each disease process so that you can... use this knowledge to verify the diagnosis code or to query the physician for accurate coding. Generally speaking, sepsis is the body's deadly response to an infection. In other words, It is an overwhelming total body inflammation so overwhelming that it is treated as an urgent, life-threatening condition.
Sepsis is often the result of an infection in the lungs, kidneys or urinary tract infection. It can also result when the immune system has been weakened by trauma, burns or chronic conditions such as cancer or diabetes. These are signs and symptoms of SIRS, Systemic Inflammatory Response Syndrome. Rapid heart rate greater than 90 beats per minute. Rapid breathing rate more than 20 breaths per minute.
Fever. Temperature greater than 104 Fahrenheit or hypothermia when temperature drops below 98.6 Fahrenheit. abnormal white blood cell or leukocytosis when white blood cell count of retinol 12 000 cells per cubic millimeter low pco2 or low pressure of carbon dioxide Next, sepsis is defined as such due to an infection.
Therefore, in order to be diagnosed with sepsis, an individual must have at least two such criteria and a confirmed or suspected infection. Next, severe sepsis is defined as such due to an infection that progresses to organ dysfunction, such as kidney or heart failure. In order to call a patient, with severe sepsis. The documentation should clearly indicate that organ failure is related to sepsis.
If it's not clear, you should always query the physician for verification. And last septic shock is the form of severe sepsis where the organ dysfunction involves the lungs, kidneys and liver. Septic shock is life-threatening and requires immediate medical treatment.
It is the most severe state of sepsis and the mortality rate for septic shock is about 40 percent. Early and aggressive treatment is critical for survival. Treatments include IV fluid and possibly vasopressor to restore blood flow.
Prospectin antibiotics are usually used first while waiting for culture results. After learning the results of the blood test, the physician may switch to different antibiotics that target to fight the particular bacteria causing the infection. Sepsis coding guidelines If you are currently working as a DRG or inpatient coder or planning to take the CCL exam in the near future then you got to know sepsis coding guidelines Based on the study of National Library of Medicine, sepsis is highly undercoded in administrative data. In other words, hospitals are losing money or revenue on these cases, either due to poor documentation or coding errors.
That being said, I want you to pay close attention to this slide and the next few slides to take note. First, when the reason for admission is sepsis and the type of infection or causal organism is not specified, then you are cycled A41.9 for sepsis on specified organism. Second, when the reason for admission is severe sepsis, then it requires a minimum of two calls.
First, a call for underlying systemic infection A40 to A41 or B37.7, followed by a call from subcategory R65.2, severe sepsis with over-dial septic shock. Next, septic shock. As I explained previously, septic shock is a form of severe sepsis, where the organ dysfunction involves the lungs, kidneys, and liver.
Therefore, septic shock meets the definition for severe sepsis. The code for the systemic infection A40 to A41 should be sequenced first, followed by code R65.21, severe sepsis with septic shock, or code T81.12, post-procedural septic shock. Any additional codes for the other acute organ dysfunction should also be assigned.
Sepsis coding. When you have a patient record listed with bacteremia as the final diagnosis, then you need to go through the entire record totally and completely looking for organ dysfunction. to make sure it's not really a case of sepsis. Again, bacteremia is the presence of bacteremia in the bloodstream after a trauma or infection. And after reviewing the record thoroughly, there is no documentation of sepsis or any organ dysfunction, then you need to assign code R78.81 for bacteremia.
Next, septicemia. There is no code for septicemia in RC10-CM. Instead, you are directed to a combination code for sepsis to indicate the underlying infection such as a 41.9 sepsis on specified organism for septicemia with no further detail.
sepsis and septic shock complicating abortion, pregnancy, childbirth and puperium. A cycle from chapter 15 to 16 first, followed by a call for the specific time of infection. If severe sepsis is present, a cold form subcategory R65.2 should also be assigned. If you are new to my channel, then you should watch my videos titled How to Call Pregnancy and Delivery and How to Call a Newborn Record so that you get yourself familiar with the cold forms chapter 15 and 16. Before I talk about the sepsis coding guidelines and sequencing, I want you to open the IC10CM book and do some coding exercise. Let's do it.
Question 1. Code the following diagnosis anaerobic gram negative sepsis. I will put on a short 30-second music while waiting for you to open Yaxi Tencent book and find the right call for this diagnosis. Please pause the video and do it now. I hope the music will wake you up and book you in a great mood to study.
Alright, let's see how you did. In the index in your IC10-CM book, if you look under the main term sepsis, subterm anaerobic, it will give you one code, A41.4. Your next step is to double check this code in the tabular list and here's what you find. A41.4, sepsis due to anaerobics. And this is the right code to use for this diagnosis.
Having said that, the correct answer to this question is A41.4. Question number two. Call the following diagnosis. Sepsis due to methicillin resistant staphylococcus aureus commonly referred to as MRSA.
I will book on a short 30-second music while waiting for you to open Yaxi Tencent Second book and find the right call for this diagnosis. Please pause the video and do it now. Alright, let's see how you did. In the index in your C10CM book, if you under the main term sepsis subterm staphylococcus methicillin resistant MRSA, it will show you one code A41.02.
Your next step is to double check this code in the tabular list and here's what you find. A41.02, sepsis due to methicillin resistant Staphylococcus aureus. And this is the right code to use for this diagnosis. Having said that, the correct answer to this question is A41.02.
Now, you already know how to look up codes for sepsis. So, I'll talk about sepsis coding guidelines and sequencing. Sequencing of severe sepsis.
How you call and sequence the call will determine the appropriate DRG and reimbursement for an inpatient record. If you are currently working as an inpatient coder or thinking about taking the CCS exam, then you got to know the sequencing of severe sepsis. If the reason for admission is sepsis or severe sepsis with a local infection such as pneumonia or sepsis, the call for systemic infection A40 to A41 should be sequenced first, followed by the call for the local infection, pneumonia or sepsis.
If the patient has severe sepsis, a call from subcategory R65.2 should also be assigned. Next, if the patient is admitted with a local infection such as pneumonia, pneumonia, and sepsis, severe sepsis, doesn't develop until after admission, the low-collar infection should be assigned first, followed by the appropriate sepsis or severe sepsis course. And this is one of the reasons why hospitals are required to submit present-odd admission POA indicators. In other words, For every single diagnosis code that you assign on an inpatient record, you need to specify whether that condition existed before or after the patient came to the hospital.
Regardless of how serious the condition is, if it's not present on admission, then it cannot be designated as the principal diagnosis. I say it again. This is one of the reasons why hospitals are required to submit present or admission POA indicators. In other words, for every single diagnosis code that you assign on an inpatient record, you need to specify whether that condition existed before or after the patient came to the hospital. Regardless of how serious the condition is, If it's not present on admission, then it cannot be designated as the principal diagnosis.
I hope you will remember this concept. Sepsis was not infectious condition. sepsis and severe sepsis associated with a non-infectious process condition, such as burns or trauma, and this condition meets the definition for principal diagnosis.
The code for the non-infectious condition should be sequenced first, followed by the code for the resulting infection. If severe sepsis is present, a code from subcategory R6512 should also be assigned with any associated organ dysfunction codes. You may wonder, how do I know if a condition meets the definition for principal diagnosis?
If this is the case, then you need to ask yourself this question. Would the patient have been admitted to the inpatient setting for this condition? Or did this condition necessitate inpatient admission? Was the treatment significant enough?
If the treatment is just a pill of medication and not an IV fluid or IV medication, then it could be treated as an outpatient. Therefore, it doesn't meet the definition of principal diagnosis. I want you to keep this in mind. Slowly but surely, you will become an inpatient coder before you know it.
So keep learning. If the infection meets the definition of principal diagnosis, it should be sequenced before the non-infection condition. When both the non-infection condition and the infection meet the definition of principal diagnosis, either may be assigned as principal diagnosis.
due to device implant and graft. The cold-formed category T82 or T83 should be sequenced first, followed by the cold for the specific infection. For example, T80.211A sepsis due to central venous catheter initial encounter or T83.511A sepsis due to inguinal urethral catheter initial encounter. Sepp's it due to a post-procedural infection.
A call from T81.40 to T81.43 infection following a procedure should be coded first, followed by the call for the specific infection. For example, T81.44XA sepp's it following a procedure. I hope that you did pay attention and take note so you are ready for more coding challenge exercise. Let's do it.
Question number three. The patient presents with fever, cures, elevated WBC, white blood cell count, shortness of breath, cough and mental static change. Upon admission, the patient is documented with possible sepsis and check x-ray confirmed pneumonia.
Patients were treated with IV antibiotics with improvements and was able to be discharged on day 4 of admission. The final diagnosis is sepsis due to pneumonia. What diagnosis call are reported for this admission? Now you have all information that you need highlighted So I will put on the short 30 second music while waiting for you to open Yaxi Tencent book and find the right code for this case Please pause the video and do it now Alright, let's see how you did.
In this case, since the sepsis was present on admission and the final diagnosis confirmed sepsis due to the underlying infection of pneumonia, you have to follow the RCTNCM official coding guideline. If the reason for admission is sepsis or severe sepsis with a local infection such as pneumonia or cell cellitis. The code for the systemic infection A40 to A41 should be sequenced first followed by the code for the local infection, pneumonia or cell cellitis. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned.
Based on this coding guideline, the code for the systemic infection A40 to A41 should be sequenced first, followed by the code for the local infection, and in our case, it is a pneumonia. So let's go back to our question. Since the type of infection or causal organism is not specified, you have to assign code A41.9, sepsis, unspecified organism.
And it must be the first listed code and will be designated as the principal diagnosis. And next, J18.9, pneumonia, unspecified organism. That said, the correct answer to this question is A41.9 and J18.9.
Question number 4. The out-of-sit patient presents with fever, cures and auto-mental status. Walk-up. This review is extremely high on WBC, white blood cell count, on labs.
After admission. and the diagnosis of sepsis was made. Infectious disease saw the patient and recommended removal of the arteriovenous AV craft.
that the patient had been using for dialysis, the patient will remain on IV antibiotic for 6 weeks and then removal will be scheduled. The discharge diagnosis given is sepsis due to IV graft infection. What cause are assigned?
I already underlined and highlighted the key points of the report. So all you need to do now is open Yashiten's book and find the right codes for this case, please pause the video and do it now. Alright, let's see how you did.
In this case, since the sepsis was present on admission and the final diagnosis confirmed sepsis due to AV graft infection, you have to follow the RC10 official coding guideline, sepsis due to device implant and graft. Based on this coding guideline, The code from category T82 or T83 should be sequenced first, followed by the code for the specific infection, and in our case, it is the infection of the AV-Dialysis graph. So let's go back to the question. In the index India C10 CM book, if you look under the main term, complication, subterm vascular, device or implant, infection, it will give you just one code, T82.7-.
And it means that this code is not complete. It needs more digits. Your next step is to always double check this code in the tabular list.
And here's what you find. T82.7-SSA, infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter. This is the right code to use for this condition, and it must be listed first to be designated as the principal diagnosis according to the coding guideline.
Next. An additional code A41.9 shapes it on specified organism. It also be assigned based on the coding guideline to identify the infection.
That said, the correct answer to this question is T82.7XXA in A41.9. Just a fairly reminder that if you enjoy what you have learned so far and appreciate my time spent for this video, then you could please pause the video, click the like, subscribe and share buttons below now to support my channel and that would be great. Even small gestures can mean a lot to me. These are free lectures, but I put a lot of time into it, and I didn't come this far without motivation. You are my motivation.
I really want you to do well on the exam, and to have more confidence at work. Thank you so much for your support, and we should move on to the next question. Question number 5. Before I started, If you are currently working as an inpatient coder or want to become an inpatient coder in the future, then you got to know how to code this case.
Alright, let's read, analyze and take note. The discharge diagnosis for a patient admitted with urosepsis due to streptococcus and white blood cell count of 15,000 colonies. Urine culture and blood culture were positive for streptococcus. First in the IC10-CM, if you look under the mental urosepsis, there will be no code for it. So it will be coded as a simple UTI urinary tract infection.
Second, the physician sometimes uses the term urosepsis to describe both septicemia and a UTI, so you need to query him or her to find out what diagnosis is intended. On a side note, based on what I just read, an elevated white blood cell count WBC equal or greater than 15,000 colonies can be an indicator of exception. Now, let's say I didn't go one step further, which is to query physician and just call this case based on the information that I have so far. Then, I will call it as a simple UTI due to streptococcus and bacteremia to report the blood culture was positive for streptococcus.
And this case... will be grouped under DLC 690 kidney and urinary tract infection without MCC major complication and the estimated reimbursement will be $9,579 but as I said before you need to query the physician and find out what diagnosis he intended After query to the physician regarding the meaning of the term urosepsis, an addendum was added to the record, sepsis with septococcal, septicemia, and urinary tract infection, both due to septococcus B. That's great. The physician responded to my query, make an addendum and confirm it is sepsis with streptococcus septicemia and urinary tract infection both due to streptococcus B. Wow, I love coding.
Now this case is no longer a simple UTI but rather a sepsis case. Based on the IC10-SIM official coding guideline, if the reason for admission is sepsis or severe sepsis with a local infection such as pneumonia or cell cellitis, the code for the systemic infection A40 to A41 should be sequenced first followed by the code for the local infection, pneumonia or cell cellitis, and in this case it is a UTI. If the patient has severe sepsis, a cold form subcategory R65.2 should also be assigned, but it's not in our case.
Now, I have already gathered all information that you need including the coding guidelines, so I will put on a short 30-second music while waiting for you to open YI C10 CM book and find the right codes for this case. Please pause the video and do it now. Alright, let's see how you did. In the index NGIC 10 CM book, if you look under the main term sepsis, subterm streptococcus group B, it will give you one code A40.1. Follow the same step if you look under the main term infection urinary tract, it will give you just one code N39.0 and similarly If you look under the main term, Structococcus, group B, it will give you one code, B95.1.
Your next step is to double check these codes in the tabular list, and I assume you already did that, and they are the right codes to you. So the correct answer to this case is A40.1, N39.0, and B95.1. It will be grouped under DRG.
A72 septicemia or severe sepsis without MCC and the estimated reimbursement will be $12,204. So compared to DRC 690 for simple UTI, the difference in terms of reimbursement will be $2,625. Now you know why hospitals want to recruit the best and most experienced coders. Your coach will impact the hospital reimbursement significantly.
Having said that, I want you to become the best coder, and you are again there, slowly but surely, so you should keep learning. Question number six. If you have been watching my videos, then you should know my strategy by now. Instead of reading the question or procedure report first, and in some cases the reports or procedures are very long and you don't have enough time during the exam.
Not to mention, if you are new to coding, then you probably may not have a clue what you are reading. And one of the main reasons why many students failure exam is because they ran out of time. My strategy will help solve that problem.
Follow my tip and strategy. A and D have the same code. A41.50 so they are in the same group.
B and C have different code. A41.9 and R65.20 so they are in two separate groups. Now you know there are three groups so there are three codes for you to look up in the IC10CM book A41.50, A41.9 and A65.20. Please pause the video, open the IC10CM book and look them up now. I wait for you.
Assuming you already looked them up in Yashiten's same book, and here's what you find. A41.50 Crime-negative sepsis unspecified. A41.9 sepsis unspecified organisms. and R65.20, severe sepsis without septic shock. Follow my tips and strategy, you highlight the main difference between each diagnosis score.
And when you done you can tell A41.9 is for unspecified sepsis versus A41.50 is for gram negative sepsis and A65.20 is for severe sepsis without septic shock. Based on the code encryption you should have an idea what this case is about. It is about sepsis.
or C. biceps it and that's the reason why I want you to analyze the answer first and now is the time for you to read the question or the report. Let's find out. This 17 years old man was taken to the emergency department after being found semi-concert with markedly abnormal vital signs of fever of over 102 Fahrenheit, a heart rate of 100, and a respiratory rate of 22 per minute.
On admission to the ICU, the documentation stated sepsis and within one day of admission, the physician documented his condition as severe sepsis with acute respiratory failure. During the course of the admission, This patient was also treated for type 2 diabetes, hypertension and hypothyroidism. The final diagnosis provided by the physician was gram-negative sepsis with acute respiratory failure.
What cause should be assigned? Now, based on what I just read and highlighted, the final diagnosis was gram-negative sepsis with acute respiratory failure, so 81.9 does not apply. We can eliminate B from here.
Also, based on the Accenture-CM official coding guideline, called in category A40 to A41 must be sequenced first and not R65.20 or R65.21 so we can eliminate C from here. A and D still remain and they both have R65.20, J96.0, E11.9, I10 0.3.9 so we cannot use this code for our process of elimination. The only difference now is this has G79.4 which A doesn't have. So please pause the video, open Yashiten Second book and look it up now. I'll wait for you.
Assuming you already looked it up in Yashiten Second book, and here's what you find. G79.4 long-term current use of insulin. Based on the report, this patient was also treated for type 2 diabetes but there is no documentation to indicate that this patient is on insulin so G79.4 long-term current use of insulin should not be assigned.
That said, the correct answer to this case is 8. A41.50, R65.20, J96.0, E11.9, I10, and E03.9 Question number 7. Follow my tips and strategies. A, B, C, and D all have different codes. A41.9, R50.9 026.859 and 003.37 so they are in four separate groups. There are four groups so there are four codes for you to look up in Yashiten Second's book. Please pause the video and do it now.
I wait for you. Assuming you already looked them up in the Yashiten book and here's what you find. A41.9 sepsis unspecified organism. R50.9 fever unspecified. O26.A59 sporting complicating pregnancy unspecified trimester.
and O03.37 sepsis following incomplete spontaneous abortion. Follow my tips and strategy, you highlight the main difference between each diagnosis code and when you're done, you can tell the first code A41.9 is for unspecified sepsis, the second code R50.9 is for a fever. What is a sign and symptom of sepsis so it should not be a sign with sepsis and be the first code listed or a principal diagnosis? The last two codes are for pregnancy with complication. Now is the time for you to read the question or report and find out what will be the right code to use.
Let's read it. An obstetric patient is admitted. with vaginal spotting and fever. C found to have been treated for a miscarried, incomplete, spontaneous abortion, which was resolved two weeks prior to this admission.
C treated with suction, dilation and corrita. C found to be accepted. Which of the following is the correct sequencing of the diagnosis for this case?
Based on what I just read and highlighted, this patient had a sepsis following incomplete spontaneous abortion. Also, here's the general rule for obstetric case. Rules for obstetric cases, sepsis and septic shock, complicating abortion, pregnancy, childbirth and puperium. When assigning a Chapter 15 code for sepsis, complicating abortion, pregnancy, childbirth, and the puparium, a code for the specific time of infection should be assigned as an additional diagnosis.
If severe sepsis is present, a code from subcategory R65.2, severe sepsis, and codes or codes for associated organ dysfunction should also be assigned. as an additional diagnosis. Basically, when coding a pregnancy or an obstetric case, I want you to remember this important rule. Codes from chapter 15 have sequencing priority over all the chapters. in IC10-CM and they are the first code listed and will be the principal diagnosis and the call for sepsis or severe sepsis should also be assigned as an additional diagnosis.
So let's go back to our case. Based on this coding guideline, first we can eliminate A and B because R15.9 fever is a sign and symptom of sepsis so it should not be coded or listed as the first code. Second, 841.9 should not be the first code listed based on the rules for obstetric or pregnancy cases.
C and D still remain and based on the question C is found to have sepsis following incomplete spontaneous abortion so O03.37 Sepsis following incomplete spontaneous apportion is the right code to use and also should be sequenced first followed by a code for unspecified sepsis. That said, the correct answer to this question is D. O03.37 and A41.9 That is all for today.
Thank you so much for watching, for liking and sharing this video. If you find this video is helpful, informative and easy to learn with this format or if you have any suggestion, then please leave me a comment below just to let me know. I really appreciate it.
Until next time, have a great day.