ICD-10-CM Chapter 1 Certain Infectious and Parasitic Diseases, contains specific guidelines relating to the coding of Sepsis, Severe Sepsis and Septic Shock, although there is one guideline listed in Chapter 15 Pregnancy Childbirth and Puerperium, Chapter 16 Certain Conditions Originating in the Perinatal Period and in Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings; all should be reviewed and followed regarding Sepsis as well.
In Chapter 1 the code range A40 – A41.9, classifies several types of bacterial sepsis but also includes “Sepsis, unspecified organism”. When assigning a code for SIRS and Severe Sepsis, Chapter 18 is where the codes are located:
- R65.1 Systemic inflammatory response syndrome (SIRS) of non-infectious origin
- R65.10 Systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction
- R65.11 Systemic inflammatory response syndrome of non-infectious origin with acute organ dysfunction
- R65.2 Severe Sepsis
- R65.20 Severe Sepsis without Septic Shock
- R65.21 Severe Sepsis with Septic Shock
https://www.starauditing.com/blog/2017/6/18/sepsis-coding
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d. Sepsis, Severe Sepsis, and Septic Shock Infections resistant to
antibiotics
1) Coding of Sepsis and Severe Sepsis
(a) Sepsis
For a diagnosis of sepsis, assign the appropriate code for the
underlying systemic infection. If the type of infection or causal
organism is not further specified, assign code A41.9, Sepsis,
unspecified organism.
A code from subcategory R65.2, Severe sepsis, should not be
assigned unless severe sepsis or an associated acute organ
dysfunction is documented.
(i) Negative or inconclusive blood cultures and sepsis
Negative or inconclusive blood cultures do not preclude a
diagnosis of sepsis in patients with clinical evidence of
the condition; however, the provider should be queried.
(ii) Urosepsis
The term urosepsis is a nonspecific term. It is not to be
considered synonymous with sepsis. It has no default code
in the Alphabetic Index. Should a provider use this term,
he/she must be queried for clarification.
(iii)Sepsis with organ dysfunction
If a patient has sepsis and associated acute organ
dysfunction or multiple organ dysfunction (MOD), follow
the instructions for coding severe sepsis.
(iv)Acute organ dysfunction that is not clearly associated
with the sepsis
If a patient has sepsis and an acute organ dysfunction, but
the medical record documentation indicates that the acute
organ dysfunction is related to a medical condition other
than the sepsis, do not assign a code from subcategory
R65.2, Severe sepsis. An acute organ dysfunction must be
associated with the sepsis in order to assign the severe
sepsis code. If the documentation is not clear as to
whether an acute organ dysfunction is related to the sepsis
or another medical condition, query the provider.
(b) Severe sepsis
The coding of severe sepsis requires a minimum of 2 codes: first
a code for the underlying systemic infection, followed by a code
from subcategory R65.2, Severe sepsis. If the causal organism is
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not documented, assign code A41.9, Sepsis, unspecified
organism, for the infection. Additional code(s) for the associated
acute organ dysfunction are also required.
Due to the complex nature of severe sepsis, some cases may
require querying the provider prior to assignment of the codes.
2) Septic shock
Septic shock generally refers to circulatory failure associated with severe
sepsis, and therefore, it represents a type of acute organ dysfunction.
For cases of septic shock, the code for the systemic infection should be
sequenced first, followed by code R65.21, Severe sepsis with septic
shock or code T81.12, Postprocedural septic shock. Any additional codes
for the other acute organ dysfunctions should also be assigned. As noted
in the sequencing instructions in the Tabular List, the code for septic
shock cannot be assigned as a principal diagnosis.
3) Sequencing of severe sepsis
If severe sepsis is present on admission, and meets the definition of
principal diagnosis, the underlying systemic infection should be assigned
as principal diagnosis followed by the appropriate code from subcategory
R65.2 as required by the sequencing rules in the Tabular List. A code
from subcategory R65.2 can never be assigned as a principal diagnosis.
When severe sepsis develops during an encounter (it was not present on
admission), the underlying systemic infection and the appropriate code
from subcategory R65.2 should be assigned as secondary diagnoses.
Severe sepsis may be present on admission, but the diagnosis may not be
confirmed until sometime after admission. If the documentation is not
clear whether severe sepsis was present on admission, the provider
should be queried.
4) Sepsis or severe sepsis with a localized infection
If the reason for admission is sepsis or severe sepsis and a localized
infection, such as pneumonia or cellulitis, 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. If the patient has
severe sepsis, a code from subcategory R65.2 should also be assigned as
a secondary diagnosis. If the patient is admitted with a localized
infection, such as pneumonia, and sepsis/severe sepsis doesn’t develop
until after admission, the localized infection should be assigned first,
followed by the appropriate sepsis/severe sepsis codes.
5) Sepsis due to a postprocedural infection
(a) Documentation of causal
relationship
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As with all postprocedural complications, code assignment is
based on the provider’s documentation of the relationship
between the infection and the procedure.
(b) Sepsis due to a postprocedural infection
For infections following a procedure, a code from T81.40, to
T81.43 Infection following a procedure, or a code from O86.00 to
O86.03, Infection of obstetric surgical wound, that identifies the
site of the infection should be coded first, if known. Assign an
additional code for sepsis following a procedure (T81.44) or
sepsis following an obstetrical procedure (O86.04). Use an
additional code to identify the infectious agent. If the patient has
severe sepsis, the appropriate code from subcategory R65.2
should also be assigned with the additional code(s) for any acute
organ dysfunction.
For infections following infusion, transfusion, therapeutic
injection, or immunization, a code from subcategory T80.2,
Infections following infusion, transfusion, and therapeutic
injection, or code T88.0-, Infection following immunization,
should be coded first, followed by the code for the specific
infection. If the patient has severe sepsis, the appropriate code
from subcategory R65.2 should also be assigned, with the
additional codes(s) for any acute organ dysfunction.
(c) Postprocedural infection and postprocedural septic shock
If a postprocedural infection has resulted in postprocedural septic
shock, assign the codes indicated above for sepsis due to a
postprocedural infection, followed by code T81.12-,
Postprocedural septic shock. Do not assign code R65.21, Severe
sepsis with septic shock. Additional code(s) should be assigned
for any acute organ dysfunction.
6) Sepsis and severe sepsis associated with a noninfectious process
(condition)
In some cases, a noninfectious process (condition) 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, 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
R65.2 should also be assigned with any associated organ dysfunction(s)
codes. It is not necessary to assign a code from subcategory R65.1,
Systemic inflammatory response syndrome (SIRS) of non-infectious
origin, for these cases.
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If the infection meets the definition of principal diagnosis, it should be
sequenced before the non-infectious condition. When both the associated
non-infectious condition and the infection meet the definition of
principal diagnosis, either may be assigned as principal diagnosis.
Only one code from category R65, Symptoms and signs specifically
associated with systemic inflammation and infection, should be assigned.
Therefore, when a non-infectious condition leads to an infection
resulting in severe sepsis, assign the appropriate code from subcategory
R65.2, Severe sepsis. Do not additionally assign a code from subcategory
R65.1, Systemic inflammatory response syndrome (SIRS) of noninfectious origin.
See Section I.C.18. SIRS due to non-infectious process
7) Sepsis and septic shock complicating abortion, pregnancy,
childbirth, and the puerperium
See Section I.C.15. Sepsis and septic shock complicating abortion,
pregnancy, childbirth and the puerperium
8) Newborn sepsis
See Section I.C.16. f. Bacterial sepsis of Newborn