CDI Adult MDC 13 - Female Reproductive System

Question 1

Infections and Sepsis

Answer 1

• If a diagnosis of sepsis is validated as present on admission, assign sepsis as the principal diagnosis.
• If sepsis develops after the time of admission, assign sepsis as a secondary diagnosis.

If the clinical evidence supports a diagnosis of sepsis, seek clarification from the physician.

Question 2

Sepsis Clinical Indicators

Answer 2

SIRS may be clinically indicated by any 2 of the 4 following indicators in the presence of an infectious process:
― Temperature > 38°C or < 36°C

― Heart Rate > 90/min

― Respiratory Rate > 20/min or PaCO2 < 32 mmHg

― WBC > 12,000/mm3 or < 4000/mm3 or > 10% immature bands

Question 3

Sepsis testing knowledge

Clinical Scenario: A 24 yo female presents to the ED with complaints of vaginal discharge x5 days with fever and increasing lethargy x2 days. Triage VS are noted as: T102.6, P118, R22, BP 112/64. Stat blood work reveals a WBC at 27.3 with 18% bandemia. She is admitted to ICU with a diagnosis of “PID and bandemia.” Her treatment regimen includes IV vancomycin.

The CDS should seek clarification for:
A. SIRS due to infectious process
B. Sepsis
C. Sepsis, POA

Answer 3

Answer: C. Sepsis, POA

Explanation: The correct answer is sepsis, POA. There’s no diagnostic code assignment for SIRS due to infection, only a non-infectious process. Sepsis is correct, but not the best answer. Sepsis, POA is the best answer. If sepsis is present on admission with her localized infection, assign the sepsis as the principal diagnosis.

Question 4

UTI d/t Candida

Answer 4

Review the patient’s urine C&S. If the pathology is positive for candida, seek clarification of the clinical significance of the finding, especially if the treatment plan includes an antifungal medication.
* In the female patient, a Candidal UTI is considered a female reproductive infection

Candidal UTI is gender specific condition - not MDC 11 (renal) dx.

Question 5

UTI d/t Candida Clinical Example

Scenario: A 78 yo diabetic female was admitted yesterday morning with a “urinary tract infection.” This afternoon her urine C&S has returned + for Candida albicans. The physician has changed her IV antibiotics to IV Diflucan. Discharge is anticipated within 24 hours.

Sample Clarification

Answer 5

Sample Clarification:
* Urinary tract infection d/t Candida albicans requiring treatment with IV Diflucan
* Other; with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record reflects the following clinical evidence:
Clinical Indicators:urinary tract infection with + UA C&S findings for candida
Risk Factor: 68 yo female, diabetes
Treatment: IV Diflucan

Explanation: A 78-year-old female has been admitted with UTI. Her C&S has returned positive for yeast and her antibiotic regimen has been changed to IV Diflucan. We’ll ask the physician if the patient has a urinary tract infection due to candida requiring treatment with IV Diflucan.

Question 6

Ovarian Cancer
* Clinical Indicators
* Treatment
* Complications

Answer 6

• Clinical indicators – pain, swelling, pressure in the abdomen/pelvis, vaginal bleeding, vaginal discharge, palpable mass in the pelvis, miscellaneous GI complaints.
• Treatment incudes surgery, chemo, radiation.
• Complications: Toxic GE, AKI, neuropathy, intestinal perforation, peritonitis, intra-abdominal abscess, malignant pleural effusion, non-infectious SIRS, metastasis.

If there’s clinical evidence of a complication that is not documented, seek clarification from the physician.

Cancers of the ovaries, fallopian tubes, and primary peritoneum are the fifth leading cause of cancer death in women in the U.S.

Question 7

Stages used for ovarian epithelial, fallopian tube, and primary peritoneal cancer

Answer 7

• Stage I: In stage I, the cancer is found in one or both of the ovaries (or fallopian tube).
• Stage II: In stage II, the cancer is found in one or both ovaries and tubes and has spread into other areas of the pelvis.
• Stage III: In stage III, the cancer is found in one or both ovaries or tubes and has spread outside the pelvis to the abdominal cavity or lymph nodes.
• Stage IV: In stage IV, the cancer has spread beyond the abdominal cavity to other parts of the body, such as the pleural fluid, or lymph nodes in the groi

Question 8

Ovarian Cancer Complication: Intestinal Perforation
* Is this considered a medical emergency?
* Definition
* Clinical Indicators
* Treatment

Answer 8

• considered an emergent condition associated with high mortality.
• Any part of the gastrointestinal tract may become perforated and cause spillage of the intestinal contents into the peritoneal cavity, leading to the development of peritonitis, intra-abdominal abscess, and sepsis.
• Clinical indicators – abdominal pain, N.V, tachycardia, elevated WBC.
• Treatment often requires surgical intervention unless the leak is “walled off.”

Question 9

Chemotherapy Administration
* What is the principal diagnosis if a patient is admitted for the administration of chemotherapy?
* What Root Operation is used to index the procedure?
* Is Chemotherapy Administration a Valid or Non-valid OR Procedure?

Answer 9

• If a patient is admitted for the administration of chemotherapy, your principal diagnosis will be “encounter for chemo,” not the neoplasm.
• Root operation = INTRODUCTION to index the procedure
• Non-valid OR Procedure

Introduction: putting in or on a therapeutic substance except blood or blood products

Question 10

Radiation Therapy
* Is Radiation Therapy a valid or non-valid OR procedure?
* What Root Operations are included?
* What determines the Root Operation to index this procedure?
* In addition to the root operation, what characters will be identified in Radiation Therapy? Where can this information be obtained?

Answer 10

• Radiation therapy is a non-valid OR procedure

Root Operation = Beam Radiation
Root Operation = Brachytherapy
* Radiation can be delivered either as beam radiation or as brachytherapy. You will use the root operation that describes your patient’s radiation protocol, e.g., beam radiation or brachytherapy.

• Identify the treatment part, the modality qualifier, the isotope, and the qualifier. This information is obtained from the procedure note - If you are still unsure of a character, ask a question.

Question 11

Brachytherapy

Answer 11

Delivers radioactive seeds into or adjacent to the tumor.

Question 12

Hysterectomy
* Partial
* Complete/Total
* Radical

Answer 12

• Partial - removal of the fundus and body of the uterus but not the uterine neck (cervix).
• Complete/Total - removal of the entire uterus, i.e., fundus, body, and cervix.
• Radical - the entire uterus and a portion of the vagina are removed.

Question 13

Abdominal (TAH)

Hysterectomy Approaches

Answer 13

An incision is made in the abdominal wall to expose the ligaments and blood vessels around the uterus. The ligaments and blood vessels are separated from the uterus and the blood vessels tied off. Then, the uterus, with the cervix, is resected at the top of the vagina. The top of the vagina is repaired to form a vaginal cuff.

Indications: cancer, large fibroid(s)

Question 14

Vaginal (TVH)

Hysterectomy Approaches

Answer 14

The uterus and cervix are resected through an incision in the vagina. As with the TAH, the top of the vagina is repaired to form the vaginal cuff.

Indications: uterine prolapse, no possibility of cancer

Question 15

Laparoscopic (LAVH)

Hysterectomy Approaches

Answer 15

During an LAVH, several small incisions (3-5) are made in the abdominal wall through which trocars are inserted to provide access for a laparoscope and other surgical instruments. The uterus is resected from the ligaments that attach it to other structures in the pelvis and removed through an incision at the top of the vagina which is repaired to form a vaginal cuff.

Question 16

Laparo-endoscopic single site (LESS)

Hysterectomy Approaches

Answer 16

This procedure is performed through an approximately one-inch single incision in the fold of the belly button which avoids the large six- to eight-inch incision required for an open hysterectomy and the multiple incisions required for standard laparoscopic surgery. The uterus is resected from the ligaments that attach it to other structures in the pelvis and removed through an incision at the top of the vagina which is repaired to form a vaginal cuff. After the LESS hysterectomy, the incision is covered by the natural contours of the belly button, hiding the scar. This advanced surgical technique reduces the pain and minimizes the scarring compared to an open approach.

Question 17

Robotic-assisted laparoscopic hysterectomy

Hysterectomy Approaches

Answer 17

This robotically assisted laparoscopic hysterectomy provides the surgeon with a 3D/HD view inside the pelvic cavity, “wristed” instruments that bend and rotate with greater dexterity than the human hand, and enhanced vision, precision, and control. As a result of this technology, there is a lower rate of complications, short LOS, and less blood loss.

Question 18

Hysterectomy
Root Operation

Answer 18

The root operation RESECTION since in most instances the entire uterus is removed.

Resection: cutting out or off, without replacement, of a body part

Question 19

Total Open Hysterectomy:
Requires the capture of the Resection of what 2 body parts?

Answer 19

A “total open hysterectomy” requires the capture of the resection of the uterus AND the resection of the cervix

• The cervix is considered a separate body part; if the cervix is removed, you’ll need to add an additional resection for the cervix

Question 20

Total Hysterectomy - Coding Clinic 3Q 2013, p28

Question: How is a total hysterectomy performed via an open approach coded? Is it appropriate to assign ICD-10-PCS codes for both the resection of the uterus and the cervix, when only a total hysterectomy is documented in the operative report?

Coding Clinic Advice

Answer 20

Answer:
For a total (open) hysterectomy, assign the ICD-10-PCS codes as follows:
0UT90ZZ, Resection of uterus, open approach
0UTC0ZZ, Resection of cervix, open approach

A total hysterectomy includes the removal of the uterus and cervix. Therefore, code both the resection of uterus and cervix. This is supported by the ICD-10-PCS Official Guidelines for Coding and Reporting, which state, “During the same operative episode, multiple procedures are coded if: The same root operation is performed on different body parts as defined by distinct values of the body part character.”

Explanation: This Coding Clinic advice from 2013 addresses the question concerning a total hysterectomy and whether it is appropriate to assign resections for the uterus and the cervix. According to Coding Clinic, you’ll assign both procedures – the resection of the uterus and a separate procedure for the resection of the cervix.

Question 21

Hysterectomy DRG Assignment
* In the female MDC, hysterectomy is assigned according to what?
* The Surgical DRGs are assigned according to?

Answer 21

• In the female MDC, hysterectomy is assigned according to the patient’s PDx. Ensure you’ve selected the principal diagnosis best supported by the documentation in the medical record.

The surgical DRGs are assigned according to:
* ovarian/adnexal* malignancy
*adnexa in this context = fallopian tube/broad ligament
* uterine malignancy
* all other female diagnoses (ex: uterine fibroid)

Question 22

Control of Post-operative Bleeding - Coding Clinic 4Q2016, p100

Question: The patient underwent laparoscopic supracervical hysterectomy and bilateral salpingo-oophorectomy. After the uterus, tubes and ovaries had been removed, rapid bleeding was noted from the site of the laparoscopic port. The surgeon converted to an open approach by extending the incision to control the bleeding in the abdominal cavity. The bleeding was then controlled with suture. The physician documented in his diagnostic statement, “Complication, bleeding right inferior epigastric artery.”

What are the appropriate diagnosis and procedure code assignments for the intraoperative bleeding?

Coding Clinic Advice

Answer 22

Answer:
Assign code I97.42, Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating other procedure, for the intraoperative bleeding, since the surgeon documented the bleeding of the right inferior epigastric artery as a complication. There was no mention of puncture or laceration. Assign also code Z53.31, Laparoscopic surgical procedure converted to open procedure. Assign the follow ICD-10-PCS code:
0W3F0ZZ Control bleeding in abdominal wall, open approach

This is not a typical surgical case where “achieving hemostasis” is considered integral to the procedure, since the surgeon opened the patient up to control the bleeding of the abdominal wall (where the trocar went through). Therefore, a separate procedure code for control of bleeding is appropriate in this case.

Explanation:

In this 2016 Coding Clinic, a patient undergoes a laparoscopic supracervical hysterectomy with bilateral S&O. After the organs were removed, rapid bleeding was noted from the laparoscopic port. The surgeon converted to an open procedure to control hemorrhaging from the right inferior epigastric artery. The HIM professional seeks advice for the capture and coding of this additional diagnosis and surgical work. According to Coding Clinic, assign a diagnosis for an intra-operative hemorrhage complicating the procedure. You’ll capture the additional surgical work with a procedure code that describes control of bleeding in the abdominal wall using an open approach.

Question 23

Testing Knowledge

Clinical Scenario: A 63 yo female has been admitted for an elective total abdominal hysterectomy d/t stage III uterine cancer. She is 2 days s/p TAH. As you review the medical record, you find that her postop H&H is noted at 9 and 24 in today’s progress note with a diagnosis of “anemia.” She has been typed and cross matched for 2 units of blood – one unit is currently infusing. Of note, her pre-op H&H was 12 and 32.

Questions:
1) What is the patient’s principal diagnosis?
A. total abdominal hysterectomy
B. stage III uterine cancer
C. anemia

2)Is there clinical evidence of a potential secondary diagnosis?
A. Yes
B. No

3) The potential secondary diagnosis is:
A. DVT
B. ABLA
C. Postop wound infection
D. Dehiscence

Answer 23

Answers:
1) B. stage III uterine cancer
2) A. Yes
3) B. Acute Blood Loss Anemia

Explanation: A 63-year-old female with stage 3 uterine cancer has been admitted for elective TAH. Postoperatively her H&H drops from 12 and 32 to 9 and 24 and she’s been diagnosed with anemia. She’s currently receiving a transfusion of blood. Her principal diagnosis is uterine cancer, but there is clinical evidence of an important secondary diagnosis – acute blood loss anemia.

Question 24

Pelvic Evisceration
* Definition
* Root Operation
* What must the coder remember to do when assigning the root operation for this patient?

Answer 24

All organs are removed from the female pelvic cavity including the: uterus, tubes, ovaries, cervix, vagina, bladder, urethra, rectum, anus, external genitalia in some instances
* Root Operation = Resection
Use the root operation “resection” to index the procedure and remember to assign each resection separately.

Extensive metastasis of MDC 13 neoplasm may require pelvic evisceration.

*Pelvic evisceration also assigns to other MDCs, so validate your patient’s principal diagnosis before assuming an MDC 13 surgical assignment. For example, if the pelvic evisceration is performed for a digestive malignancy, such as colon cancer, you will assign the colon cancer as the principal diagnosis and the pelvic evisceration from MDC 6, the digestive MDC rather than MDC 13.

Question 25

Pelvic Evisceration - Complications

Answer 25

small bowel obstruction, ABLA, AKI, hypovolemic shock, POWI, wound dehiscence, urinary diversion fistula, colostomy complication, perineal hernia.

Continuously monitor the medical record for clinical evidence of a complication - about 50% of patients will develop a post-op complication.

Question 26

Postoperative Wound Infection (POWI)

Answer 26

• A broad category of conditions that includes sepsis, infected sutures, and several different types of abscesses (retroperitoneal, superficial, deep, organ/space) that occur in the postoperative period. There is NO time frame used to establish a post-operative wound infection – it is left to the discretion of the physician.

POWI category does not include infections that are due to a device, therapeutic injection, postoperative fever, or obstetrical wound infections.

Question 27

Lymph Node Dissection

Answer 27

Resection: cutting out or off, without replacement, all of a body part
Excision: cutting out or off, without replacement, a portion of a body part

• If a chain of lymph nodes is excised, it should be coded as resection.
• If a partial removal of the lymph node chain is done, it is coded as excision.
• If the intent is to remove all of the lymph nodes in an area, code as resection.
• A radical resection implies removal of all of the lymph nodes.
• If the entire chain is removed, use the root operation Resection.

Hysterectomy or pelvic evisceration may or may not include the removal of lymph nodes.

Question 28

Vulvectomy

Answer 28

• A partial vulvectomy removes only the affected area and a margin of tissue around the cancer.
• The modified radical vulvectomy removes the affected area, an edge of tissue for a clear margin, and usually removal of some lymph nodes.
• If there’s cancer in or very near the clitoris, the clitoris may be resected.

The most extensive surgery is the radical vulvectomy, which is rarely ever done. The entire vulva is resected, but the internal organs (vagina, uterus, ovaries) remain intact.

Question 29

Vulvectomy Most Common Complications

Answer 29

• postoperative wound infection
• wound dehiscence
• lymphangitis
• lymphedema

Question 30

Adhesiolysis

Answer 30

During an adhesiolysis, organs are being released from abnormal physical constraint. For patients requiring an adhesiolysis, you’ll use the root operation RELEASE since the intent of the procedure is to release an anatomical structure from a band of adhesions.

Important Note: When a release is performed, none of the constrained organ is removed. Appropriate assignment requires the capture of each organ released during the adhesiolysis; laterality may be required, e.g., right ovary.

Release: Freeing a body part from an abnormal physical constraint by cutting or by the use of force

Surgical MSDRG assignment for adhesiolysis in MDC 13 is determined by the organ or organs released during the procedure. However, do not assume that adhesiolysis is always performed for pelvic adhesions in the female patient.

Question 31

If the patient is admitted for an Adhesiolysis d/t pelvic pain (an MDC 13 dx) but a review of the operative report reveals minimal adhesions in the pelvis but adhesiolysis occurring primarily in the abdominal cavity, seek clarification of?

Answer 31

abdominal pain d/t adhesions (an MDC 6 dx).
* The adhesiolysis in MDC 6 would be assigned instead of the adhesiolysis in MDC 13.

*The female pelvis is a basin shaped cavity bordered by the pelvic girdle and sacrum containing and protecting the bladder, rectum and female reproductive organs.

**The abdominal cavity lies between the diaphragm and pelvis and contains and protects the abdominal organs.

Question 32

Adhesiolysis Clinical Example

Scenario: A 65 yo female has been admitted for pelvic pain d/t adhesions. She has a significant surgical history, including an open cholecystectomy, incisional hernia repair and total abdominal hysterectomy. Prior to surgery, she localized the pain to her pelvis. The operative report reveals adhesiolysis of extensive abdominal adhesions with minimal adhesions noted in the pelvic cavity.

Sample Clarification

Answer 32

Sample Clarification:
* Abdominal adhesions requiring adhesiolysis
* Pelvic adhesions requiring adhesiolysis
* Other; with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record reflects the following clinical evidence:
Clinical Indicators: minimal adhesions in the pelvis
Risk Factor: multiple abdominal surgeries
Treatment: adhesiolysis of extensive abdominal adhesions

Explanation: In this scenario a 65-year-old female has been admitted for pelvic pain due to adhesions. She’s had multiple abdominal procedures in the past including an open cholecystectomy and abdominal hysterectomy – procedures associated with abdominal adhesion development. A review of the operative-report reveals minimal adhesiolysis occurring in the pelvis but extensive adhesiolysis performed in the abdomen. In this scenario, we’ll seek clarification of the patient’s principal diagnosis. Review the clinical evidence cited in the body of the clarification.

Question 33

female stress Incontinence

Answer 33

inability to prevent the escape of urine when additional pressure is placed on the bladder and/or pelvic floor (ex: laughing, coughing, sneezing, lifting)

MDC 13 FEMALE DIAGNOSIS

Question 34

urge incontinence

Answer 34

involuntary loss of urine that usually occurs when a person has a strong, sudden need to urinate

MDC 11 RENAL DIAGNOSIS

Question 35

mixed incontinence

Answer 35

a combination of stress and urge incontinence

MDC 11 RENAL DIAGNOSIS

Question 36

urethral hypermobility

Answer 36

weakness of the urethral sphincter muscle; the sphincter does not function properly no matter the position of the urethra or bladder neck

MDC 11 RENAL DIAGNOSIS

Question 37

intrinsic sphincter deficiency

Answer 37

inability of the pelvic floor muscles to provide support to the urethra and bladder neck resulting in bladder neck movement downward causing involuntary leakage of urine; usually results from childbirth, pelvic surgery, hormone changes

MDC 11 RENAL DIAGNOSIS

Question 38

Clinical Scenario: A 44 yo female has been admitted for surgical intervention for her “stress incontinence.” However, as you review the medical record, you find that she also describes frequent, sudden urges to urinate that also cause her to experience incontinence.

Question: What alternative PDx is supported by the clinical evidence?
1. Urge Incontinence
2. ISD
3. Mixed Incontinence

Answer 38

Answer: 3. Mixed Incontinence

Explanation: Remember this question from the MDC 11 module? In this female patient, it’s important to seek clarification of mixed incontinence. Her diagnosis of stress incontinence is considered an MDC 13 diagnosis, but she also has symptoms of urge incontinence. Validating the diagnosis of mixed incontinence with the physician will reassign your principal diagnosis and surgical procedure from the female MDC to the renal MDC.

Question 39

Surgical Intervention for Urinary Incontinence

Answer 39

Patients with urinary incontinence, especially female stress incontinence will often require surgical intervention to improve their quality of life. Most surgical procedures to treat stress incontinence fall into two main categories:

• sling procedures
• bladder neck suspension procedures

Question 40

Sling Procedure

Answer 40

For a “sling” procedure, the surgeon will use strips of synthetic mesh, autologous or non-autologous tissue to create a sling to support the urethra and/or bladder neck. The support from the sling helps to keep the urethra closed and prevent involuntary urination.

There are two “types” of sling procedures: tension free and conventional.

Question 41

Tension-free sling

Answer 41

No sutures are used to attach the tension-free sling, which is made from a strip of synthetic mesh tape. Instead, body tissue holds the sling in place. Eventually, scar tissue forms in and around the mesh to keep it from moving.

Question 42

Conventional sling

Answer 42

An incision is made in the vagina, and the sling is passed under the bladder neck. Through a second abdominal incision, the sling is pulled to achieve the desired amount of tension and then sutured to pelvic or abdominal wall fascia.

Question 43

Bladder neck suspension

Answer 43

Reinforces the urethra and bladder neck using sutures attached to ligaments near the pubic bone.

Question 44

What is the Root Operation to index the Urinary “Sling” Procedure

Answer 44

During a urinary “sling” procedure the surgeon repositions the angle of the urethra in order to improve its function, You’ll use the root operation REPOSITION to index the procedure.
* Reposition: Moving to its normal location, or other suitable location, all or a portion of a body part

Question 45

What is the Root Operation to index Procedures that require the use of supplemental materials, such as mesh or non-autologus tissue (eg A bladder neck suspension)

Answer 45

Some procedures used for urinary incontinence will require the use of supplemental materials, such as mesh or non-autologous tissue. To index the procedure use the root operation SUPPLEMENT.
* Supplement: Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part

Question 46

Pubovaginal Sling - Coding Clinic 1Q 2016, p15

Question: A patient with a history of stress urinary incontinence presents for pubovaginal sling placement. What is the appropriate ICD-10-PCS code for this procedure? Specifically, we are not sure what the appropriate approach value would be for this procedure.

Coding Clinic Advice

Answer 46

Answer: For the pubovaginal sling placement, assign the following ICD-10-PCS procedure code:

0TSD0ZZReposition urethra, open approach
The purpose of the procedure is to reposition the angle of the urethra so that it is not hypermobile, and the goal is to move the urethra into proper position. Structurally the sling is holding the urethra in place and changing the angle so that it does not leak. The urethra is not deficient; its in the wrong place. The tape helps to keep it in the correct position but is not performing the function of the urethra. Therefore, Reposition is the appropriate root operation.

Reposition is defined as putting in or putting back or moving some or all of a body part to its normal or other suitable location. Additionally, the approach is open, because the operative report states that flaps were raised on either side of the groin through two small incisions in order to perform the procedure. This means that the site of the procedure was exposed to direct visualization and therefore the approach is open.

Explanation: In this Coding Clinic advice from 2016, a patient undergoes a pubovaginal sling for stress incontinence. The coding professional seeks advice concerning the approach value. According to Coding Clinic, the approach value for this procedure is open based on a review of the operative report. The operative report states flaps were raised on either side of the groin, through two small incisions, in order to perform the procedure. This means the site of the procedure was exposed to direct visualization; therefore, the approach is open.

Question 47

The patient has stage 3 uterine cancer with metastasis to the right ovary. She has been admitted for resection of the ovary. Her principal diagnosis is uterine cancer.

A. True
B. False

Answer 47

B. False

If the patient is admitted for treatment of a secondary site even if the primary site still exists, the principal diagnosis is the secondary site.

Question 48

Chemotherapy places the patient at risk for pancytopenia due to chemotherapy.
A. True
B. False

Answer 48

Answer: A. True

Chemotherapy does place your patient at risk for pancytopenia; don’t forget to ask this important question if the clinical evidence supports the question.

Question 49

In the patient admitted with pelvic peritonitis and sepsis, both present on admission, the localized infection (peritonitis) is sequenced as the principal diagnosis with a secondary diagnosis of sepsis.
A. True
B. False

Answer 49

Answer: B. False

If the patient is admitted with a localized infection and sepsis, and sepsis meets the definition of principal diagnosis, you’ll assign sepsis as the principal diagnosis

Question 50

2 of 4 SIRS criteria may be clinically indicative of SIRS d/t a non-infectious process, such as cervical cancer.
A. True
B. False

Answer 50

Answer: A. True

2 of 4 SIRS criteria will potentially support a diagnosis of non-infectious SIRS in patients with non-infectious conditions like cancer.