Question

An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." How should this case be coded?

a) N39.0, R65.21
b) N39.0, R65.20
c) N39.0, R65.22
d) N39.0, R65.23

Answer 1

The case should be coded as N39.0, R65.21. N39.0 represents 'urinary tract infection, site not specified', and R65.21 represents 'severe sepsis with septic shock.'

Step-by-step explanation:

If an 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC, and has more than 100,000 organisms of Escherichia coli per cc of urine, the attending physician would document the case as 'urosepsis.'

The correct code to use for this case is option a) N39.0, R65.21. N39.0 represents 'urinary tract infection, site not specified', and R65.21 represents 'severe sepsis with septic shock.'