Health Information Management

Q&A: Sepsis as a primary diagnosis

CDI Strategies, May 19, 2016

Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

Q: If a physician documents sepsis due to decubitus ulcer and UTI due to indwelling catheter, can sepsis be coded as the primary diagnosis since it is due to both the ulcer and UTI?
A: This is an interesting question. If the sepsis results from an indwelling catheter or a complication of a device, the complication code would be sequenced first. In this instance, I would likely code the complication code first with sepsis as a secondary diagnosis.
However, clarification may be needed to determine whether the physician is actually stating that the UTI led to sepsis. Without the entire record, it is difficult to determine. Is the physician stating the sepsis is due to the decubitus ulcer and the UTI? Or is the provider stating sepsis due to decubitus ulcer and a secondary diagnosis of UTI due to indwelling catheter? If this differentiation is unclear, a query would be needed.
If the documentation supports the fact the sepsis is due to the decubitus ulcer only, then I would sequence the sepsis first. The Official Guidelines for Coding and Reporting offer us much guidance related to the sequencing of sepsis. They clearly state that if the reason for admission is both sepsis and a localized infection, such as pneumonia or cellulitis, a code for the underlying systemic infection should be assigned first and a code for the localized infection should be assigned as a secondary diagnosis.
Now, another guideline is used when the sepsis results due to a surgery or device. So, if the provider has determined both the decubitus ulcer and the catheter associated infection contributed to the sepsis, we would follow the guidelines and coding conventions related to sepsis as a complication. We would assign the T83.51 code for the infection due to the device first, followed by the additional code to identify the infection as a secondary code.


Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at For information regarding CDI Boot Camps visit

Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular