Severity
with MCC
What Axiom does
From discharge record to claim-ready codes
Axiom reviews the medical record, assigns and validates the appropriate codes, applies the Official Coding Guidelines, calculates the MS-DRG, and produces a fully justified coding sheet with supporting evidence for each decision.
Medical recordinCodesICD-10-CM / PCSMS-DRGgroupedCoding sheetout
For coding teams
Every coding decision, fully supported
Each coding decision is documented in a complete coding summary, including the selected code, the clinical evidence from the record, the reasoning behind the decision, and the applicable coding guideline. Codes that were considered but not selected are also documented, with a clear explanation of why they were excluded.
Summary of the case
82 y/o · Female1 principal + 5 secondary DxMS-DRG 871 · with MCCDischarged: Home with home health
An 82-year-old female presented with confusion, fever, and dysuria. She was found to have sepsis due to a urinary tract infection with Escherichia coli confirmed on urine culture, complicated by severe sepsis with acute hypoxemic respiratory failure requiring supplemental oxygen and acute kidney injury from sepsis and hypoperfusion. She was treated with resuscitation including IV fluids, with lactate normalization, creatinine improvement, and eventual weaning from oxygen over the hospital stay. The patient was discharged home with home health services.
Why this coding
I assigned A41.51 (Sepsis due to Escherichia coli) as the principal diagnosis because the patient was admitted for treatment of sepsis and the urine culture grew E. coli, making the systemic infection the condition chiefly responsible for the encounter. Secondary codes capture the localized source (N39.0 urinary tract infection with B96.20 identifying E. coli as the causative organism per the use-additional-code instruction on N39.0), the severe sepsis manifestation (R65.20), and the acute organ dysfunctions (J96.01 acute respiratory failure with hypoxia and N17.9 acute kidney failure). The grouper assigned MS-DRG 871 based on this combination of codes.
MS-DRG 871
Septicemia or Severe Sepsis without MV >96 Hours with MCC
82 y/o · F · disch. Home with home health
MDC 18
Infectious & Parasitic Diseases
Type
MED
Rel. weight
1.9425
Diagnoses & procedures
PDX
A41.51
Sepsis due to Escherichia coli [E. coli]MCC
I chose A41.51 as the principal diagnosis because the record states the patient was ‘treated for sepsis’ and the ‘urine culture grew Escherichia coli,’ with documentation of ‘Sepsis due to a urinary source.’ Per Guideline I.C.1.d.4, when sepsis with a localized infection is the reason for admission, the underlying systemic infection code is assigned first as principal. A41.51 specifically identifies E. coli as the causative organism, matching the culture result.
“treated for sepsis”
“urine culture grew Escherichia coli”
Rule I.C.1.d.4Section I · 4) Sepsis or severe sepsis with a localized infectionICD-10-CM Official Guidelines for Coding and Reporting
“a code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis”
Rule I.C.1.d.3Section I · 3) Sequencing of severe sepsisICD-10-CM Official Guidelines for Coding and Reporting
“the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2”
confidence 100%
SDX
N39.0
Urinary tract infection, site not specifiedCC
I chose N39.0 as a secondary diagnosis because the record documents ‘Urinalysis was consistent with a urinary tract infection’ and ‘Urinary tract infection due to Escherichia coli, present on admission.’ Per Guideline I.C.1.d.4, the code for the localized infection is assigned as a secondary diagnosis when sepsis is the reason for admission. No specific site such as cystitis or pyelonephritis was documented, so N39.0 (site not specified) is the correct code; the Excludes1 list does not include unspecified UTI.
“Urinalysis was consistent with a urinary tract infection”
“Urinary tract infection due to Escherichia coli, present on admission”
Rule I.C.1.d.4Section I · 4) Sepsis or severe sepsis with a localized infectionICD-10-CM Official Guidelines for Coding and Reporting
“the code for the localized infection should be assigned as a secondary diagnosis”
confidence 100%
Deployment
Runs where your data lives
The same system, two ways to run it. On-premise, nothing leaves your network at all. In the cloud, records are de-identified inside your walls first, so no identifiable patient data ever leaves the hospital.
On-premise
Inside your walls
Axiom runs on a server in your own network. No internet connection required: records are processed and stay where they already are.
Your hospital
Medical recordsCoding by AxiomCoded cases
Cloud
De-identified first
Records are stripped of identifying information inside your network, before anything is sent. Axiom codes the de-identified record and returns the result.
Your hospital
Medical recordsDe-identification
↓ de-identified record leaves
Axiom cloud
Coding by Axiom
↓ coded case returns
Your hospital
Coded cases
Pilot program
Prove it on your own cases
We are opening a small number of pilot slots. Axiom codes records your team has already coded: side by side, on-premise if you prefer, with zero impact on production.