Q: Patient is admitted with documented UTI, clinical picture and treatment given fit for sepsis, but "sepsis" is not documented per physician, only documented as positive blood cultures for E. Coli (drawn on admission) and SIRS. Treated with IV Levaquin. Can the coder code to the bacteremia code as the principle diagnosis from the stated "positive blood cultures" or must the coder only code the principle diagnosis as the UTI with a secondary code of the SIRS? As per Coding Clinic 2ndQ2000 and 4thQ93 the principle diagnosis should be the condition that caused the SIRS, so do you agree the SIRS should not be the principle diagnosis?
A: The challenge of coding the diagnosis of "bacteremia" is one that surfaces quite frequently with coders throughout the country. Bacteremia is sometimes used interchangeably with the clinical term of sepsis by physicians. To answer your question, let's take a look at the interrelationship of the clinical entities in the case of a patient admitted with a documented urinary tract infection, blood cultures that grow positive for E. Coli and documented SIRS.
This patient was admitted with a urinary tract infection and what was described as a clinical evidence of sepsis, that is elevated temperature, shaking chills, rigor, elevated white blood count with a left shift and altered mental status. In order of decreasing frequency, the etiologies of sepsis are UTI, respiratory, gastrointestinal and integumentary system. Additionally, the patient developed positive blood cultures, described as bacteremia by the physician. The diagnosis of bacteremia is problematic in that bacteremia by definition is bacteria in the blood, nothing more, nothing less. The physician did not indicate the significance of the positive blood culture except to state "bacteremia." The term bacteremia is considered an abnormal laboratory value and hence explains why it is classified under ICD-9 classification to signs, symptoms and ill-defined conditions. In general, the physician should not be using the terminology of "bacteremia" if there is suspected or presumed clinical significance of the bacteremia. The clinical significance of the positive blood cultures should be well described and explicitly documented by the physician, such as positive blood cultures from an ischemic, ruptured bowel, positive blood cultures from a ruptured appendix, positive blood cultures from a urinary tract infection, positive blood cultures from a seeded valve and so forth and so on.
Without further qualification from the physician, you should not assign the bacteremia as the principal diagnosis in this case. As you point out, SIRS or systemic inflammatory response syndrome is discussed in the 2nd quarter 2000 Coding Clinic. In this Coding Clinic, SIRS is described as a clinical response to an insult, infection, or trauma, that includes systemic inflammation, elevated or reduced temperature, rapid heart rate and respiration and elevated white blood count. The medical community recognizes SIRS as a major complication of infection or trauma. For patients admitted with septicemia, the symptoms of SIRS are generally present. This same Coding Clinic goes on to point out that while there are no sequencing restrictions on the SIRS codes, generally they will be listed as secondary codes. The principal diagnosis should be the infection or the trauma that brought the patient in.
Getting back to your case, the principal diagnosis should be UTI with secondaries of SIRS and bacteremia, in light of the incomplete documentation by the physician. A better alternative is to seek clinical clarification from the physician, attempting to identify the clinical significance of the patient's positive blood cultures and bacteremia and its relationship to the UTI and the SIRS. If anything, capitalize upon the opportunity to use this case as a "teaching tool" for the physician, making the point that sepsis and bacteremia are not clinical entities of the same nature.
Glenn Krauss, RHIA, CCS, CCS-P
Q: We appreciated the article in the July 21, 2003 ADVANCE regarding E-codes. However, one question remains. Could you clarify what is considered a "late effect" of an injury? Our ER coders see accounts where patients have been injured previously (days to weeks ago) and return for further treatment (to the Emergency Room). When a patient is seen after their initial visit or after the initial injury, do we use the "late effect" e-code with a current injury code or would we use a late-effect injury code?
A: Coding Clinic, March-April 1986, pg. 4 defines a late effect as the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebrovascular cases, or it may occur months or years later, such as that due to a previous injury.
If the patient presents for simple follow up in the "acute phase" of injury (i.e., fracture care), I would advise coding the fracture code/follow up fracture code.
If the patient presents after the "acute phase" (i.e., developing malunion/nonunion fracture), I would advise sequencing the residual condition/nature of the late effect first, followed by the code for the cause of the late effect. If the late effect is due to an injury, a late effect E code should also be assigned.
Look for the following terms when determining if a condition is a late effect:
Due to previous injury or illness
Following previous injury or illness
Traumatic, unless there is evidence of current trauma
Remember that the code for the acute phase of an illness or injury that led to the late effect is never used with a code for the cause of the late effect.Michelle Duffy RT(R),CPC,CPC-H
Q: What is going to happen to the CCI edits and other instructions for Medicare coding when the HIPAA Transactions and Code Sets requirements are implemented in October 2003? Only the Coding Clinic and CPT Assistant are official sources of coding instructions. Will G-codes and other Level II codes be used for all payers?
A: The Administrative Simplification provisions of HIPAA direct the federal government to adopt national electronic standards for automated transfer of certain health care data between health care payers, plans and providers. This will enable the entire health care industry to communicate electronic data using a single set of standards, thus eliminating all nonstandard formats currently in use.
The Administrative Simplification provisions of HIPAA primarily deal with facilitating national electronic standards, leaving specific coding instructions and guidance still with the Cooperating parties of the Coding Clinic and the AMA's CPT Assistant. Level II codes and G codes will apparently comprise the standards of coding while Level III codes will be eliminated. Most Fiscal Intermediaries and Carriers have recently been issuing memos and medimessages to providers outlining the elimination of local codes and modifiers.
Glenn Krauss, RHIA, CCS, CCS-P
Q: How do you code for removal of infected mesh from a ventral hernia repair? What CPT code would I use?
A: The proper CPT code would be 10121, Incision and removal of foreign body, subcutaneous tissues, complicated. The ICD-9-CM code would be 8605, Removal of foreign body from skin and subcutaneous tissue.
C. C. Moreland, MD
Q: What is the appropriate procedure for call coverage? For example: in a solo surgical practice, one surgeon rotates weekend coverage with surgeons from another practice (different tax i.d.'s). For the weekend that he is covering, is he able to bill for hospital services provided to the post-operative patients of the other surgeons? He did not assist or in any way participate in the surgeries. Does he have to bill as the other surgeon would or are daily care visits to other surgeons' postoperative patients reimbursable?
A: The answer to your question is that the covering physician seeing a patient in a global period is not able to bill for his services associated with cross coverage of a patient. This is in line with the principle of global billing under Medicare and the majority of other third party payers. I talked to several business colleagues who are surgeons and they explained that cross coverage for surgeons is a regular event in the hospital setting and office setting. The covering physician sees the patient postsurgically as a courtesy to the other surgeon, with the understanding the courtesy will be reciprocated at a future time.
Glenn Krauss, RHIA, CCS, CCS-P
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