Case Study: Sepsis with Bacteremia

Case:  A 75 year old woman is admitted with UTI, fever 101.5, altered mental status, tachycardia, BUN 50 and WBC 15,000.  Admission diagnosis is “severe UTI with leukocytosis and dehydration”.  Treatment includes IV Cipro 400mg q12h and aggressive IV fluid resuscitation.  The next day all blood cultures are positive for E. coli.  Further progress notes state: “Severe UTI with bacteremia”.  On the third hospital day ID consultant diagnoses “Sepsis due to UTI” and repeats this diagnosis twice.  What is the principal diagnosis?  Is a query necessary to clarify

Answer:  The principal diagnosis is sepsis, and no query is needed.   As found in the Key Reference section of the CDI Pocket Guide, four of the clinical signs and symptoms of sepsis were present on admission: fever, tachycardia, altered mental status, and leukocytosis.  The Official Coding Guidelines for resent on Admission reporting indicate that a condition is considered present on admission if its signs and symptoms were present at the time of admission, regardless of the time it takes “after study” to make the diagnosis

Occasionally, we hear the mistaken impression that there is a “conflict” between the diagnoses of sepsis and bacteremia which should be clarified by the attending physician. However, “bacteremia” is a Chapter 16 symptom code that simply means “positive blood culture”.  It is a manifestation of, and intrinsic to, sepsis when they occur together and cannot be assigned as the principal diagnosis.

Admission for UTI and Altered Mental Status

Case:  An otherwise healthy, 85 year old was admitted with fever and altered mental status, no vomiting. Urinalysis showed WBC, RBC and positive nitrite; urine culture ordered (no blood cultures).  IV Cipro and IVF at 100 cc/hr started with clear liquid diet.  Vital signs were normal with Temp of 100.2°F, WBC 8,000.  Brain CT scan showed mild chronic atrophy.  Neurology consult requested, and  MRI of the brain and neuro-checks every 6 hrs were ordered.  Diagnosis was “acute mental status alteration due to UTI and fever”.  What is the principal diagnosis and MS-DRG?

Answer:  As currently documented, UTI is the principal diagnosis (DRG 690 – UTI w/o MCC), even hough the focus of this admission is the symptom of altered mental status requiring extensive neurological evaluation.  The UTI itself could probably have been treated as an outpatient with oral Cipro, were it not for the mental status alteration.  However, as discussed in the Signs and Symptoms section of theCDI Pocket Guide, altered mental status is classified by ICD-9 as a Chapter 16 symptom code which cannot be sequenced as principal diagnosis when routinely associated with, or attributed to, a definitive diagnosis.  In this case, the altered mental status was attributed to the UTI.  

The solution to this diagnostic documentation and coding dilemma is clarification that the altered mental status actually represents metabolic encephalopathy which was the necessary cause and focus of admission in this case.  Encephalopathy (which is a definitive diagnosis, not a symptom) would then become the principal diagnosis resulting in the higher-weighted DRG 071 (Nonspecific Cerebrovascular Disorders w/ CC) that accurately reflects the patient’s actual condition and severity of illness.