If a physician diagnoses “sepsis” but no mention of septicemia, and blood cultures come back negative, can you still code “Septicemia” in I2100?
When you search for septicemia in the ICD-10 coding guidelines, you are cross-referenced to see sepsis & specify the type of organism or use the unspecified code. Therefore, if you have a physician-documented diagnosis of sepsis with supporting documentation that the diagnosis is active in the last 7 days (i.e. UTI with fever, tachycardia, an elevated WBC count and renal failure due to UTI), then you can code in I2100 per the RAI Manual.
Center for Medicare and Medicaid Services. (2019). MDS 3.0 RAI Manual. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html
ICD-10-CM Official Guidelines for Coding and Reporting FY 2020. Retrieved from: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-Coding-Guidelines.pdf
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