A wound clinic documents a skin infection and identifies a causative organism, and the classification instructs an additional code for the organism. What should the coder do?
Select an answer to reveal the explanation.
Short Explanation
Sometimes the code set wants both the ‘where’ and the ‘what bug.’ If the Tabular says add the organism, don’t stop at the site alone. Two codes, one infection story—when the instructions say so.
Full Explanation
Many infection categories include ‘use additional code’ notes to identify the infectious agent. When documentation identifies the organism and instructions require it, both the infection site (or type) code and the organism code are assigned. Organism codes typically do not replace the localized infection code. Sepsis is coded only when sepsis is documented, not merely because an organism is identified.