Find essential information on Klebsiella pneumoniae sepsis diagnosis, including clinical documentation, medical coding (ICD-10 codes A48.3, R65.21), and healthcare guidelines. Learn about identifying, treating, and documenting this severe infection for accurate reporting and improved patient outcomes. This resource covers Klebsiella pneumoniae bacteremia, sepsis due to Klebsiella pneumoniae, and antibiotic resistance considerations for optimal clinical management.
Also known as
Other bacterial diseases
Covers sepsis due to Klebsiella pneumoniae.
Sepsis of unspecified origin
May be used if Klebsiella is not confirmed.
Pneumonia due to Klebsiella pneumoniae
For pneumonia as the source of Klebsiella sepsis.
Klebsiella pneumoniae as the cause of diseases classified elsewhere
Use as a secondary code with conditions like pneumonia.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the Klebsiella pneumoniae infection systemic?
Yes
Is there organ dysfunction?
No
What is the localized infection site?
When to use each related code
Description |
---|
Klebsiella pneumoniae sepsis |
Escherichia coli sepsis |
Pseudomonas aeruginosa sepsis |
Coding sepsis without documented organ dysfunction due to Klebsiella pneumoniae infection leads to overcoding and potential denials. CDI should query for clarity.
Missing or inaccurate coding of the Klebsiella pneumoniae infection source (e.g., pneumonia, UTI) impacts DRG assignment and reimbursement. Thorough documentation is crucial.
Coding SIRS due to Klebsiella pneumoniae as sepsis without meeting sepsis criteria leads to inaccurate reporting and inflated severity. CDI should ensure appropriate documentation.
Patient presents with suspected Klebsiella pneumoniae sepsis. Symptoms include fever, chills, tachycardia, tachypnea, and hypotension. The patient reports recent onset of [Specify source of infection, e.g., pneumonia, urinary tract infection, surgical site infection]. Laboratory findings reveal leukocytosis with a left shift, elevated procalcitonin, and positive blood cultures for Klebsiella pneumoniae. The patient meets the criteria for sepsis based on the Sepsis-3 definition, demonstrating an acute organ dysfunction as evidenced by [Specify organ dysfunction, e.g., elevated lactate, altered mental status, low urine output]. Differential diagnoses considered include other bacterial infections, viral infections, and non-infectious inflammatory conditions. Given the positive blood cultures and clinical presentation, a diagnosis of Klebsiella pneumoniae sepsis is made. Treatment plan includes initiation of broad-spectrum antibiotics, specifically [Specify antibiotic regimen, e.g., piperacillin-tazobactam, meropenem], fluid resuscitation with crystalloids, and supportive care including oxygen therapy and vasopressor support as indicated. Patient will be closely monitored for response to therapy and complications such as septic shock, acute respiratory distress syndrome, and multi-organ failure. Further investigations will include repeat blood cultures, imaging studies as appropriate (e.g., chest X-ray, CT scan), and source control measures depending on the primary site of infection. ICD-10 code B96.3 Klebsiella pneumoniae as the cause of diseases classified elsewhere, and code R65.21 Severe sepsis will be utilized for billing and coding purposes. The patient's prognosis is guarded and depends on the severity of organ dysfunction, response to treatment, and presence of comorbidities. Continuous reassessment and adjustment of the treatment plan will be performed as needed.