Q&A: CAUTI and sepsis sequencing

Q: Why would the principal diagnosis be catheter-associated urinary tract infection (CAUTI) when sepsis is also present? I thought it would be always be sepsis.

A: You are right, in general, if sepsis is present on admission we would sequence it first. The Official Guidelines for Coding and Reporting instruct us to sequence the systemic infection first. (Section 1C1d4):

“Sepsis and severe sepsis with a localized infection: If the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis.”

A CAUTI would be assigned a complication code. The Guidelines offer us instruction related to complication codes. (Section 1C1d5b)

“Sepsis due to a postprocedural infection:

“(a) Documentation of causal relationship: As with all postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the infection and the procedure.

“(b) Sepsis due to a postprocedural infection: For such cases, the postprocedural infection code, such as T80.2, Infections following infusion, transfusion, and therapeutic injection, T81.4, Infection following a procedure, T88.0, Infection following immunization, or O86.0, Infection of obstetric surgical wound, should be coded first, followed by the code for the specific infection. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.”

The coding conventions—instructions within the Alphabetic Index and Tabular List—also support the sequencing of the complication code. At the code grouping T83.5-, the Tabular list instructs us to use an additional code to identify the infection—meaning the complication code would be sequenced first. This is one of the very few times when sepsis present-on-admission is NOT sequenced as the principal diagnosis. It would be a secondary diagnosis, providing a MCC.

I know these rules are difficult to understand as they seem to change, without any discernable pattern of logic. When you are using your encoder or are told to sequence in a certain manner that does not seem to make sense, return to the code book and read the Guidelines specific to the chapter and the guidance within both the Alphabetic Index and the Tabular List.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.