ICD-10 Coding for Urinary Tract Infection with Sepsis(A41.51, R65.21)
Complete ICD-10-CM coding and documentation guide for Urinary Tract Infection with Sepsis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Urinary Tract Infection with Sepsis
Urinary tract infection, site not specified
Used to specify the underlying infection causing sepsis.
Infection and inflammatory reaction due to indwelling urinary catheter
Used when UTI is catheter-associated.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| A41.51 | Sepsis due to Escherichia coli [E. coli] | Use when sepsis is confirmed to be due to E. coli infection. |
|
| R65.21 | Severe sepsis with septic shock | Use when sepsis is accompanied by shock and organ dysfunction. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for UTI with sepsis
Essential facts and insights about Urinary Tract Infection with Sepsis
Primary ICD-10-CM Codes for urinary tract infection with sepsis
Decision Criteria
clinical Criteria
- Positive blood culture for E. coli
documentation Criteria
- Explicit documentation of sepsis due to E. coli
Applicable To
- Sepsis due to E. coli
Excludes
- Bacteremia (R78.81)
Clinical Validation Requirements
- Positive blood culture for E. coli
- SIRS criteria met
Code-Specific Risks
- Incorrect organism identification
Coding Notes
- Ensure organism specificity is documented.
R65.21 - Severe sepsis with septic shock
Use when sepsis is accompanied by shock and organ dysfunction.
Applicable To
- Septic shock
Excludes
- Sepsis without shock (A41.-)
Clinical Validation Requirements
- Documentation of organ dysfunction
- Evidence of septic shock (e.g., hypotension)
Coding Notes
Link organ dysfunction to sepsis explicitly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Urinary tract infection, site not specified
N39.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Urinary Tract Infection with Sepsis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code A41.51.
Impact
Clinical: Inaccurate severity assessment, Regulatory: Non-compliance with coding standards, Financial: Potential reimbursement loss
Mitigation Strategy
Ensure all organ dysfunctions are documented, Use templates to guide documentation
Impact
Reimbursement: May lead to incorrect DRG assignment and reimbursement issues., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Document 'sepsis due to UTI' with organism specificity.
Impact
Incorrect coding of sepsis without proper documentation
Mitigation Strategy
Implement regular documentation audits and training.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Urinary Tract Infection with Sepsis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Urinary Tract Infection with Sepsis
Use these documentation templates to ensure complete and accurate documentation for Urinary Tract Infection with Sepsis. These templates include all required elements for proper coding and billing.
Emergency Department Admission for UTI with Sepsis
Specialty: Emergency MedicineRequired Elements
- History of Present Illness (HPI)
- Physical Exam Findings
- Laboratory Results
- Assessment and Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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