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Sequencing Sepsis and COVID-19

Published on 

Tuesday, April 14, 2020

 | RAC Information 
 | FAQ 

Q:

What is the principal diagnosis if a patient presents to the hospital with Sepsis and COVID-19?




A:

If a patient has COVID-19 that has progressed to sepsis, we are instructed to see Section I.C.1.d. Sepsis, Severe Sepsis, and Septic Shock.  If sepsis meets the definition of principal diagnosis, sepsis should be sequenced first, followed by COVID-19. 

When COVID-19 meets the definition of principal diagnosis, and sepsis develops after admission, code U07.1 (COVID-19) should be sequenced first, followed by the appropriate code for sepsis.

Remember:  Code only confirmed cases of COVID-19

If a physician documents “presumed” COVID-19, and has tested positive for the virus, code U07.1 (COVID-19) as confirmed.  A positive test at a local or state level can be coded as COVID-19.  The Center for Disease Control and Prevention (CDC) confirmation of local and state tests for the COVID-19 virus is no longer required.

If a physician documents “suspected”, “possible”, “probable”, or “inconclusive” COVID-19, do not assign code U07.1.  Assign a codes(s) explaining the reason for the encounter such as fever, or contact with and (suspected) exposure to other viral communicable diseases (Z20.828).

Resources:

ICD-10-CM Official Coding and Reporting Guidelines (April 1, 2020 through September 30, 2020)

https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

https://www.cdc.gov/nchs/data/icd/ICD-10-CM-April-1-2020-addenda.pdf

American Hospital Association (AHA) Coding Clinic webinar ICD-10-CM Coding for COVID-19

Watch the FREE AHA webinar on COVID-19 and receive one CEU.  https://www.codingclinicadvisor.com/webinar/icd-10-cm-coding-covid-19

Article Author: Susie James, RHIT, CCS
Susie James, RHIT, CCS, is the Manager of Inpatient Coding Services at MMP, Inc. Susie has worked in the coding field for over 30 years and has worked as a coder, coding supervisor, and corporate coding manager for a large multi-facility system in Birmingham. She also worked for Alabama Quality Assurance Foundation (AQAF) as a coding reviewer/auditor before joining the team at Medical Management Plus, Inc. Susie has previously served as the President of the Alabama Association of Health Information Management (AAHIM) on the Board of Directors and currently serves as the Education/Coding Roundtable Chair. She is also a member of the American Health Information Management Association (AHIMA) and has previously served as the Co-chair for AHIMA's Leadership Team. She also served as a facilitator at AHIMA's 85th National Convention in Atlanta Georgia.

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.