Q&A: How to handle physicians who keep using the term ‘bacteremia’
Q: My physicians use the term “bacteremia” frequently and are treating it. The patient may be febrile and receiving antibiotics, but they cannot figure out a source. What should they be calling it? Or, better yet, what query should I be sending?
A: This is a very common scenario and often requires substantial physician education to change documentation behaviors. Many physicians use the terms bacteremia and sepsis interchangeably and often believe that both terms imply the patient has sepsis. Additionally, physicians don’t know about the differences in coding rules related to these conditions and the effect their documentation may have on code assignment.
So, physician education will likely need to be your first step. Part of that education should include an explanation that code R78.81, Bacteremia, is a symptom code with an Exclude1 note stating it can’t be used with sepsis and that additional documentation related to the cause of the infection, i.e., gram-negative bacteria, salmonella, etc., would be needed for correct code assignment.
R78.81 should not be used to indicate the presence of sepsis. The term bacteremia only refers to the presence of bacteria in the bloodstream and not the infectious process. The Official Guidelines for Coding and Reporting, Section I.C.1.d.1.a, instruct us to “assign the appropriate code for the underlying systemic infection, if the type of infection or casual organism is not further specified, assign code A41.9, Sepsis, unspecified organism.”
Consider also explaining that as a principal diagnosis, the condition of “bacteremia” will not likely meet medical necessity for an inpatient stay. Sepsis would.
Here’s an example of what a query might look like, bearing in mind that the specifics of the encounter as documented in the medical record would need to be included.
Mr. Remier, a 72-year-old was admitted from a skilled nursing facility on 07/28/21, presented with a fever of 101, with a respiratory rate of 110. The medical record reports that his skin was cool and clammy. Progress note from today states that his blood cultures were positive but with no source of infection identified. The treatment includes IV antibiotics.
Based on the above information, could you please clarify the diagnosis you are treating.
- Sepsis: ______
- Sepsis has been ruled out: ______
- Bacteremia (abnormal lab finding does not indicate systemic illness): ______
- Other: ______
- Clinically unable to determine: ______
Editor’s Note: Sharme Brodie, RN, CCDS, CCDS-O, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at email@example.com. For information regarding CDI Boot Camps, click here.