Q&A: Osteomyelitis versus cellulitis

Q: Is there a difference between osteomyelitis and cellulitis? And if so, do I need to query the physician for the conflicting diagnoses? The hospitalist mentions cellulitis of the foot and the wound consult is osteomyelitis of foot.

A: In short, yes, there is a difference between “cellulitis” and “osteomyelitis”

Cellulitis is an infection of the skin and the deep underlying tissues. Usually, it’s caused by bacterial infection involving streptococcus and staphylococcus, but it could be caused by other types of bacteria. Symptoms could include fever, chills, swollen glands or lymph nodes, and there could be tenderness or pain along with a rash.

For coding purposes, the acuity of the cellulitis is not necessary; it is based on the physician documentation that the condition exists (by a hands-on treating provider) and the site of the cellulitis. I would review the record to see if the patient has any clinical evidence of sepsis and query the provider if those indicators are present. I would also review the record for any indication that an excisional debridement has been performed, based on the depth of the excisional debridement, it may move the MS-DRG assignment from a medical to a surgical DRG.

Osteomyelitis, on the other hand, is an infection of the bone that may be acute, subacute, or chronic. It is usually caused by a bacteria or fungi with the most common cause being staphylococcus. Symptoms can also range from fever, fatigue, irritability, swelling, tenderness, and redness, along with warmth at the area. I would review the record again for signs/symptoms of sepsis and for a possible bone biopsy being performed.

Anytime there is an infection present, whether systemic or localized, we want to encourage the provider to identify the responsible organism, presuming it can be identified, and have them link the infection to the organism. This may seem like an easy task (and sometimes it may be), but remember, positive cultures are not necessary for the diagnosis of an infection or the organism present. A physician may diagnosis the patient based on their presentation, presenting signs/symptoms, or their response to treatment. Remember to always provide education prior to querying a physician.

I am not sure in this question who performed the wound consult, but remember that coding is based on a hands-on treating provider’s documentation with the attending physician’s documentation superseding all others in the medical record. We are limited to what we can code from a wound consult performed by a nurse. The Official Guidelines for Coding and Reporting tell us that any time there is conflicting information in the medical record, we should query for clarification.

I would also suggest that you read the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice (updated in 2016) to help you with writing your queries.

Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.