Q&A: Choosing the most appropriate principal diagnosis

Q: A 79-year-old male nursing home patient presents with lethargy, confusion, and fever after failing an outpatient course of Bactrim for a suspected urinary tract infection (UTI). His white blood count is 22,000, segs 85, bands 10, and blood cultures are negative. He has a temperature of 102°, his blood pressure is 94/60.

His urine is cloudy and brown. A bolus of fluid is given in the emergency room (ER) with subsequent dramatic improvement in the patient’s mental status. The ER physician admits the patient for “fever workup and UTI” and documents urosepsis. Patient is treated with IV antibiotics, Tylenol, and continued IV fluids.

Given the rule of “when a symptom is followed by contrasting /a comparative diagnosis, the symptom code is sequenced first,” should the principal diagnosis be fever with the UTI as the MCC/CC?

A: The provider documentation said “fever workup and UTI.” “Fever workup” is just a comment about what is planned, not a diagnosis. In addition “fever” is a symptom code and coding guidelines state that a symptom should not be sequenced as the principal diagnosis when a definitive diagnosis is known. In this case, “urosepsis”—which has been documented, is a diagnosis (599.0—the same code as UTI).

If you were to go ahead and code the fever the code would be 780.61, Fever presenting with conditions classified elsewhere. However, any code from the 780 range is considered a symptom, another clue to look elsewhere for the principal diagnosis. If you were to look up 780.61 in the code book here is what you’d find:

780.61, Fever presenting with conditions classified elsewhere

Code first underlying condition when associated fever is present, such as with:

leukemia (codes from categories 204-208)

neutropenia (288.00-288.09)

sickle-cell disease (282.60-282.69)

The phrase “code first” means that you would first code the condition/disease causing the fever and a few examples, not the complete list, are provided.  In other words, due to the coding direction “code first” this code (780.61) could never be the first-listed or principal diagnosis. So, here’s how the scenario plays out:

• Principal diagnosis: UTI
• Procedure: None
• MCC/CC: None
• MS-DRG Assignment:  MS-DRG 690, UTI without MCC
• Query opportunity? Yes. Query the physician to clarify the term “urosepsis.” There won’t be a code for urosepsis in ICD-10 so start making this diagnosis an educational priority, if you haven’t done so already.  You would want to ask the physician (if appropriate) if he/she is treating the patient for a localized infection (urosepsis/UTI) or a systemic infection (sepsis due to a urinary tract infection or from a urinary source).
  Before you query, investigate the clues of failed outpatient antibiotics, hypotension, and altered mental status.  Evaluate additional lab results, assess how “sick” the patient is and include that information in your query.  The scenario above stated that the patient’s mental status improved with hydration, so I wouldn’t necessarily jump on the “sepsis” bandwagon. And although the blood pressure appears somewhat low, this may be within normal parameters for this patient. Assess what this patient’s baseline is, a very important step prior to querying for any diagnosis.
• Query/potential DRG (only if the patient meets clinical parameters and the documentation and treatment plan support the diagnosis): DRG 872, Sepsis with UTI as a secondary diagnosis

Editor’s Note: Lynne Spryszak, RN, CCDS, CPC-A, AHIMA-Approved ICD-10 CM/PCS Trainer, answered this question. At the time of this article's original release, she was the CDI Education Director for HCPro Inc., in Danvers, MA.