Chapter 1 - Certain Infectious and Parasitic Disease (Part 2)

on Tuesday, 22 October 2013. All News Items | Coding

Sepsis, Severe Sepsis and Septic Shock

In ICD-10-CM, there are some terminology changes and revisions. An example in Chapter 1 is that the term Sepsis has replaced Septicemia.

Sepsis is a potential life threatening disease in which the body has a reaction to the presence of pathogenic organisms or toxins that have been released in the bloodstream and tissues.

  • Also call “blood poisoning”.
  • Patients with Sepsis will appear very sick.
  • Diagnosis based on clinical signs and symptoms of infection or systemic inflammation and not on location of infection.
  • Sepsis can be diagnosed without positive blood cultures especially when the patient has recently been treated with antibiotics.
  • Signs and symptoms can be different from person to person.
    • Elderly 80 year old female with UTI may have fever, tachycardia with an increase in white blood count
    • A 3 year old child with appendicitis may have low body temp and low white count.
  • The same signs and symptoms for Sepsis can also be caused by other disorders.

Coders should never code Sepsis based solely on clinical signs and symptoms alone. Provider clarification and documentation is imperative for the correct code assignment.

Note: When coding Sepsis, it is very important to read the Coding Guidelines and to stay abreast with the ever-changing quarterly updates.

Sepsis has 3 stages. Each stage is indicative of a higher level of severity.

  1. Sepsis:     Coding Guideline – Section I.C.1.d.1.a.
    • Assign the appropriate code for the underlying systemic infection showing the type of causal organism. Example:   E coli Sepsis - A41.51.
    • Assign code A41.9 for Sepsis without a specified organism documented.
    • Signs and Symptoms – Patient must exhibit at least 2 of the following:
      1. Fever above 100.4 or below 95.
      2. Heart rate (tachycardia) higher than 90 beats per minute.
      3. Respiratory rate higher than 20 breaths per minute or PaCO2<32 mmHg (4.3 kPa)
      4. Confirmed or probable infection.
      5. Shaking chills.
      6. Leukocytosis
      7. Greater than 10% immature bands
      8. Hemorrhagic skin rash
      9. Hypotension
    • The term “Urosepsis” is not to be considered synonymous with “Sepsis”.
      • There will no longer be a default code for Urosepsis.
      • Provider must be queried for clarification on whether the patient has Sepsis and/or UTI.
  2. Severe Sepsis:     Coding Guideline – Section I.C.1.d.1.b.
    • Sepsis with an associated acute organ dysfunction/failure.
      • Coding Guideline – Section I.C.1.d.1.a.iv
      • Documentation must indicate that the acute organ dysfunction is associated with the Sepsis.
      • Query provider if documentation does not clearly show whether the acute organ dysfunction is associated to Sepsis or another condition.
    • Requires a minimum of two codes:
      • Code for underlying systemic infection.
      • Following code from subcategory R65.2.
    • Additional code should also be assigned to identify specific acute organ dysfunction/failure.
    • Patient’s usually treated in ICU.
    • Signs and Symptoms – Patient must exhibit at least 2 of the signs/symptoms listed above and at least one of the following:
      1. Significant decrease in urine output.
      2. Altered mental status (AMS).
      3. Decrease in platelet count.
      4. Difficulty breathing.
      5. Abdominal pain.
      6. Acidosis
      7. Nausea and vomiting
      8. Diarrhea
      9. Cold, clammy and pale skin
  3. Septic Shock:     Coding Guideline – Section I.C.1.d.2.
    • Severe Sepsis with extreme hypotension lasting for more than one hour without the return to normal pressure following adequate IV fluid infusion or the need for vasopressors/inotropes to maintain blood pressure.
    • Code for the underlying systemic infection should be sequenced first.
    • Assign following code R65.21 – Severe Sepsis with Septic Shock.
    • Severe Sepsis with Septic Shock must be assigned if Septic Shock is documented in the medical record, even if the term Severe Sepsis is not documented.

Sepsis due to a Post-procedural Infection:     Coding Guideline – Section I.C.1.d.5.

  • Code assignment is based on provider documentation clarifying a relationship between the infection and the procedure.
  • A code for the post-procedure infection should be assigned first – Example:
    1. T83.51 - Infection and Inflammatory Reaction due to Indwelling Urinary Catheter
    2. T80.21 – Infection due to Central Venous Catheter
  • Appropriate code from subcategory R65.2 should be assigned if patient is diagnosed with Severe Sepsis along with a code to identify the associated acute organ dysfunction.

Patients at Risk

  • Elderly
  • Very young babies
  • Diabetics
  • Recently hospitalized and/or recent invasive surgical procedures
  • With wounds or injuries, such as burns
  • Weakened immune systems secondary to illnesses and/or drug therapy

Common Sources of Infection

  • Urinary Catheters
  • Surgical incisions
  • Open wounds such as pressure ulcers, burns etc.
  • Invasive devices such as IV catheters, breathing tubes etc.
  • Surgical drains
  • Prosthetic devices

Common Body Sites Where Infections May Start – (Examples)

  • Bones – (Diabetics with Osteomyelitis)
  • Bloodstream
  • Intestines – (Diverticulitis, Peritonitis)
  • Kidneys – (Urinary Tract Infection, Pyelonephritis)
  • Lungs – (Pneumonia)
  • Pancreas – (Pancreatitis)
  • Skin – (Cellulitis, Pressure Ulcers)

The implementation date of ICD-10-CM/PCS is fast approaching. ICD-10-CM/PCS will require coders to possess an in-depth knowledge and understanding of anatomy & physiology and pathophysiology.   Coders’, who are well-versed on how a body in both the healthy state as well as during the disease process should function, will be better prepared to query providers for clarification when additional documentation is required.  In turn, a coder will be able to make appropriate correlations when reviewing documentation and be able to avoid needless queries.

Article by Marsha Manning

Marsha Manning RHIT, CCS, AHIMA Approved ICD-10-CM/PCS Trainer, is an Inpatient Coding Consultant at Medical Management Plus, Inc.  Marsha has over 24 years experience in the coding profession and has held various positions such as DRG coordinator, Coding Supervisor and HIM Supervisor. In her current position, Marsha reviews records and assists clients with coding accuracy, compliance, education and Case Mix Index (CMI) as they relate to specific entities concerning Medicare. You may contact Marsha at This email address is being protected from spambots. You need JavaScript enabled to view it.This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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