If you receive a physician note with the term “urosepsis,” you may find yourself grappling with the question — is it a urinary tract infection (UTI) or a UTI with sepsis?
ICD-9 scenario: Presently, you have coding conventions to follow, which is to use 599.0 (Urinary tract infection, site not specified) for “urosepsis.” According to ICD-9 guidelines, “The term urosepsis is a nonspecific term. If that is the only term documented then only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism if known.”
ICD-10: However, ICD-10 eliminates this term. The ICD-10-Manual includes a note to “code to condition,” which means you must query the physician to determine the appropriate code assignment.
Specifically, ICD-10 guidelines state:
(ii) Urosepsis The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.
Action item: Explain to your physicians and coders “urosepsis” does not exist in ICD-10. That means your physicians should not use that term, unless they want to be bothered with queries. More specific documentation about this condition is necessary.