If a patient is admitted for both severe sepsis and a localized infection, how should the encounter be coded?

In scenarios involving both severe sepsis and a localized infection, the coding guidelines dictate that the underlying systemic infection, which is severe sepsis in this case, should be coded first. This is because severe sepsis represents a more serious condition that could lead to significant complications and requires more extensive treatment than the localized infection alone.

By prioritizing the coding of severe sepsis, you accurately reflect the most critical aspect of the patient’s condition. Following the diagnosis of severe sepsis, the localized infection can then be coded to provide a complete picture of the patient's health status. This approach aligns with the coding guidelines that emphasize capturing the most severe conditions first, especially when they involve systemic manifestations. This coding practice ensures that the severity of the patient's condition is appropriately represented for clinical documentation, research, and billing purposes.