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.
Get our CDI Pocket Guide for help documenting sepsis with bacteremia.
Receive updates on new Resources, Products, and Events.