Sepsis, Severe Sepsis, and Sepsis
Shock
You
will not find many surprises in ICD-10 for the coding of sepsis. The
biggest change is that sepsis – not identified or documented as severe – will
require the code for the sepsis. There will not be an underlying code to
indicate SIRS (Systemic Inflammatory Response Syndrome). It would
be code A41.9 if the organism is unknown or the appropriate code from A41.x if
the organism is known. Severe sepsis or sepsis with an organ
dysfunction will continue to require a minimum of 2 codes: a code from
category A41.x and a code from category R65.2x and a code for the organ
dysfunction, if known. Remember there is not a code for multi-organ dysfunction
– each one must be coded individually.
Septic
shock represents a type of acute organ dysfunction and the presence of severe
sepsis. For all cases of septic shock, the code for the underlying
systemic infection should be sequenced first, followed by code R65.21:
Severe sepsis with septic shock. This code is assigned even
if the term severe sepsis is not documented. If other acute organ
dysfunctions are document it will be coded individually.
Subcategory
R65.2x can never be assigned as a principal diagnosis. Therefore, the
underlying systemic infection should be assigned as the principal diagnosis if
severe sepsis is present on admission and meets the definition of principal
diagnosis. Be sure to query the physician if the documentation is not
clear. The following represents coding guidelines that have not changed
from ICD-9 to ICD-10.
·
If
the reason for admission is both sepsis or severe sepsis, and a localized
infection such as pneumonia or cellulitis – 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.
·
If
the patient has severe sepsis, a code from subcategory R65.2x should also be
assigned as a secondary diagnosis.
·
If
the patient is admitted with a localized infection, such as pneumonia, and
sepsis/severe sepsis does not develop until after admission, then the localized
infection should be assigned first, followed by the appropriate sepsis/severe
sepsis codes.
The
Guideline for sepsis resulting from a procedure has not changed. If
the sepsis is due to or a result of the procedure, the complication of the
procedure must be listed as the principal diagnosis (if it meets the definition
of principal diagnosis). Let’s review a few sections from the
ICD-10-CM Official Coding Guidelines.
Section
D#5, Sepsis due to a postprocedural infection:
Sepsis
resulting from a postprocedural infection is a complication of medical
care.
·
T80.2
– Postprocedural infection code.
·
T81.4
– Infections following infusion, transfusion, and therapeutic injection.
·
T88.0
– Infection following a procedure.
·
O86.0
– Infection following immunization.
Infection
of obstetric surgical wound should be coded first; followed by the code for the
specific infection. If the patient has severe sepsis the appropriate code from
subcategory R65.2x, additional code(s) for any acute organ dysfunction should
also be assigned.
Section
D#6, Sepsis and severe sepsis associated with a noninfectious process
(condition):
A
noninfectious process, such as trauma, may lead to an infection which can
result in sepsis or severe sepsis. If sepsis or severe sepsis is
documented as associated with a noninfectious condition, such as a burn or
serious injury, and this condition meets the definition for principal
diagnosis, then the code for the noninfectious condition should be sequenced
first, followed by the code for the resulting infection.
If
severe sepsis is present, a code from subcategory R65.2x should be assigned
with any associated organ dysfunction(s) codes. It is not necessary to
assign a code from subcategory R65.1x – Systemic inflammatory response syndrome
(SIRS) of non-infectious origin – for these cases. If the infection meets
the definition of principal diagnosis it should be sequenced before the
non-infectious condition. Only one code from category R65 should be
assigned.
Section
D #7, Sepsis and septic shock complicating abortion, pregnancy, childbirth, and
the puerperium:
The
rule has not changed. Sepsis will be the secondary diagnosis when
associated with the above conditions.
Please
Note – The
term urosepsis should be queried for the classification as it is not to be
considered synonymous with sepsis and should no longer default to 599.0 in
ICD-10. Also, the physician should be queried for negative or
inconclusive blood cultures as this does not preclude a diagnosis of sepsis in
patients with clinical evidence of the condition.
As
always, I hope that this information has been helpful.
References
ICD-10-CM,
“Official Guidelines for Coding and Reporting “ 2011 (Draft)
http://www.mascodingsolutions.com/
