ICD-10-CM PCS Inpatient Coding

Sepsis and Respiratory Failure: Sequencing the Principal Diagnosis Correctly By SZ Ahmed CCS Sepsis frequently coexists with organ dysfunction, such as acute respiratory failure, creating complexity for coding professionals tasked with selecting the principal diagnosis (PDX). According to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) guidelines, when both conditions are present on admission (POA) and treated, sepsis should be sequenced as the PDX if it is the underlying cause of the organ dysfunction. This article examines this guideline, offering practical examples to guide accurate coding and ensure proper Diagnosis-Related Group (DRG) assignments. Understanding Sepsis as the Driver When a patient presents with sepsis and respiratory failure, coders must determine the causal relationship. The ICD-10-CM Official Guidelines (Section I.C.1.d) state that if sepsis and acute organ dysfunction are both POA, and no other cause (e.g., trauma o...

Sepsis Coding: Ensuring the Principal Diagnosis Reflects Clinical Reality By SZ Ahmed, CCS Sepsis coding remains a high-stakes challenge for health information professionals. Accurate assignment of sepsis as the principal diagnosis (PDX) directly impacts Diagnosis-Related Group (DRG) assignments, reimbursement, and audit outcomes. The first rule of sepsis coding—clinical justification for sepsis as PDX—requires coders to verify its presence on admission (POA) and its role as the primary reason for hospitalization. This article explores this guideline, offering practical examples and strategies to ensure compliance and precision. the foundation of Sepsis as PDX Sepsis cannot be assigned as the PDX simply because it appears in the medical record. According to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) guidelines, sepsis must be POA, supported by clinical documentation (e.g., emergency department [ED] notes, history and physical [H&P...