Q:
If a physician diagnoses “sepsis” but no mention of septicemia, and blood cultures come back negative, can you still code “Septicemia” in I2100?
A:
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.
References:
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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Blog by Kristen Walden, MSN, RN, RAC-CT, Proactive Medical Review
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