Sepsis, Severe Sepsis, Septic Shock

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)

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