Dr. Knox sees a 52-year-old male with past history of hypertension, brought in by EMS for 2-days of fever and suprapubic pain. The pain is described as sudden onset, sharp, constant, 9/10, non-radiating, associated with dysuria, urgency, fever, though nothing improves or worsens his pain. His family states he has a history of alcohol abuse.  He did not take BP medication today. He denies chest pain, shortness of breath, nausea/vomiting/diarrhea, penile discharge, hematuria, blood in stool, or IV drug use.

 

Vitals:  HR 130, B/P 88/60, RR 20, Temp 38.5 , SpO2 100% on room air

Physical examination: sick appearing male, in moderate discomfort.

HEENT: mucous membranes dry, normal otherwise

CV: tachycardic, regular rhythm, no murmurs or rubs

Resp: clear, even and unlabored

Abd: soft, nondistended, moderate suprapubic tenderness without guarding, no CVA tenderness

Extremities: normal

Neuro: normal

 

The patient was given 2 liters of normal saline without appropriate response in blood pressure which remained 90/60, so a central line was placed and norepinephrine started, labs revealed an acute kidney injury with elevation in creatinine to 2.0, and urinalysis showed a urinary tract infection (UTI) without hematuria. Antibiotics were started and patient was admitted to the Medical Intensive Care Unit.

Dr. Knox records a diagnosis of “septic shock and UTI”.

 

ICD-10 requires a higher degree of specificity to correctly code sepsis with organ dysfunction and hypotension. The coding of severe sepsis with ICD-10 should include the source of infection, a UTI in this case, plus the code for severe sepsis. The old ICD-9 (995.92) designation of “Urosepsis” no longer exists.

 

The ED coder would assign the following ICD-10 diagnosis codes:

R65.21	Severe sepsis with shock
N39.0	UTI, site not specified
R30.0	Dysuria
R50.81	Fever presenting with conditions classified elsewhere
N17.9	Acute kidney failure, unspecified
R10.30	Lower abdominal pain, unspecified
F10.1	Alcohol abuse

For the Evaluation & Management service, the coder would also assign a CPT code such as 99285 or 99291 for critical care.

For additional information on ICD-10 coding for emergency medicine, visit the ACEP Reimbursement page.

08/2015