Health Information Management

Q&A: Coding for sepsis when other conditions are present

JustCoding News: Inpatient, January 6, 2010

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QUESTION: I have two questions about coding sepsis and other conditions when both are present on admission (POA) and the physician treats both conditions equally. I know the guidelines for coding sepsis, but I have to question them in two scenarios for which I was told to use sepsis as my principal diagnosis.

Case 1: A patient comes in with aspiration pneumonia and is seen choking on food prior to admission. The physician ordered an IV antibiotics and aspiration precautions. The patient has a history of aspiration pneumonia from difficulty swallowing. The physician also documents sepsis blood cultures positive and continues IV antibiotics for the patient.

Case 2: A patient comes in with diarrhea due to failed outpatient treatment of Clostridium difficile (C-diff). The patient was on antibiotics previously and developed C-diff. The patient received an IV upon admission. The physician documents sepsis upon admission and continues to treat patient with IV antibiotics.

I understand that sepsis is a systemic infection, but it’s not necessarily the cause for every other condition. Choking on the food caused the aspiration pneumonia—not the sepsis. And the long-term use of the antibiotics caused the C-diff. Can you please tell me why these are not equal principal diagnoses?

ANSWER: This is a great question. Just to reiterate, both diagnoses (i.e., pneumonia and C-diff) and the sepsis were both POA, and the physician treated both equally during the patient’s stay.

The 2010 ICD-9-CM Official Guidelines for Coding and Reporting, Section II, Selection of Principal Diagnosis states:

The principal diagnosis is defined in the Uniform Hospital Discharge Data Set as ‘that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.’

In this case, the most important part of this definition may be “established after study.” After the physician admitted the patient for the pneumonia or C-diff and sepsis, what problem became more pressing, complicated, and severe after admission when tests, treatment, and resources were expended?

If this still does not break the tie, so to speak, between the two diagnoses, perhaps this guideline will help: ICD-9-CM Official Guidelines for Coding and Reporting, Section II, subsection C states that when two or more diagnoses that equally meet the definition for principal diagnosis “any one of the diagnoses may be sequenced first.”

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at

This answer was provided based on limited information submitted to Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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