When severe sepsis is present on admission, how should the encounter be coded?

When coding for severe sepsis present on admission, the correct approach is to first code for the underlying infection, followed by the severe sepsis. This method adheres to the hierarchical structure of coding for conditions, where it's essential to identify the primary cause, which in this case is the underlying infection. The underlying infection provides the context for the severe sepsis diagnosis and demonstrates the sequence of the patient's medical condition.

By prioritizing the underlying infection in the coding sequence, you ensure that the full clinical picture is represented, which is crucial for accurate data reporting, appropriate treatment planning, and resource allocation in healthcare settings. The subsequent code for severe sepsis captures the serious nature and complications arising from that infection.

Overall, this sequencing fulfills the requirements for documenting the condition accurately, provides a comprehensive overview of the patient’s health status, and aligns with coding guidelines to promote optimal care and billing practices.