Still have confusion in Sepsis coding?

Click on https://medscorecoding.com to know more.

Are you curious about the heading! If so, give your time to read out this and solve your existing chaos in sepsis coding. I am sure that many of us would have spent a lot of time in seminar, webinar, tests and quizzes to learn about sepsis coding. However, when it comes to live coding part, we still go back behind the book, search for the guidelines and other stuffs to find out the correct codes for sepsis. Also there may arouse a lot of debates to substantiate the correct coding of different coders. Whatsoever it is, this article is surely going to bring up a solution for sepsis coding confusions. Get started!

Before jumping into the code sets and the guidelines, let’s know about the definition of these terms in short.

Definition of Sepsis:

Sepsis is defined as an extreme inflammatory response to infection. It is a potentially fatal or life changing syndrome and many clinicians consider sepsis to have three stages, starting with sepsis and progressing to severe sepsis and septic shock.

Sepsis is always confused with terms like septicaemia and SIRS (Systemic Inflammatory response syndrome). Let’s know about the difference as below:

Difference between Sepsis and SIRS: The key difference between Sepsis and SIRS is the “presence of an infection”. SIRS is accompanied by the following symptoms and it can occur following trauma, inflammation, ischemia, or infection. However sepsis occurs only in the presence of an infection.

Symptoms of SIRS:

· Temperature above 100.4 or below 96.8

· Heart rate above 90 beats per minute

· Breathing rate more than 20 breaths per minute or arterial carbon dioxide less than 32 mmHg

· White blood cell count above 12,000 or below 4,000

Difference between Sepsis and septicaemia: Septicemia is a bacterial infection that spreads into the bloodstream. Sepsis is the body’s response to that infection, during which the immune system will trigger extreme and potentially dangerous, whole-body inflammation.

Note: For sepsis, two of the mentioned SIRS symptoms, as well as an infection, need to be present

Definition of Severe Sepsis:

Severe sepsis is defined as sepsis associated with organ dysfunction, hypotension or hypoperfusion. Organ dysfunction is characterized by symptoms such as decreased urine output, sudden changes in mental state, decreased blood platelet count, difficulty breathing, and abnormal heart pumping function.

Definition of Septic Shock:

Septic shock is defined as sepsis associated with hypotension and perfusion abnormalities despite the provision of adequate fluid (volume) resuscitation. It is the most severe stage of sepsis.

SEPSIS CODING:

Every coder must know the clear definition of sepsis and its associated terms to accurately code the ICD-10 codes. Below are the official guidelines to code and report the sepsis, severe sepsis and septic shock.

To report sepsis, combination codes such as A41.9 (Sepsis, unspecified organism) or A41.51 (Sepsis due to Escherichia coli [E. coli]) must be used to include:

1. both the underlying infection (septicemia) and

2. The body’s inflammatory response to it ( SIRS)

Septicemia: There is NO code for septicemia in ICD-10. Therefore coders are directed to the combination “A” codes for sepsis to indicate the underlying infection, such as A41.9 (Sepsis, unspecified organism) for septicemia with no further detail.

The below is the screenshot from the ICD-10 CM tabular list to denote both the terms in a single combination code.

SIRS: Coders must determine whether SIRS is related to infection or if it is non-infectious. In ICD-10, “SIRS due to systemic infection” is sepsis. Non-infectious causes are the result of trauma, burns, pancreatitis, drug reaction, etc. When SIRS is due to a non-infectious cause, the non-infectious process such as trauma is coded first, followed by R65.10 — or, if organ dysfunction is present, R65.11.

Coders always require a complete and definite documentation to assign the accurate codes for sepsis. Therefore it is necessary to query the physician in the following instances:

  • Physician should be queried if the patient has clinical indicators for sepsis; however the blood cultures are negative or inconclusive.
  • Physician should be queried when the terms “Urosepsis” or “sepsis syndrome” is used.
  • Physician should be queried if the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition.

SEVERE SEPSIS CODING:

Severe sepsis is defined as sepsis with acute organ dysfunction or multi-organ dysfunction. Coding severe sepsis requires a minimum of two codes as below:

1. A code for the underlying systemic infection

2. Code from sub-category R65.2 to denote severe sepsis.

As severe sepsis is associated with organ dysfunction, additional codes for any associated organ dysfunction should also be assigned when coding severe sepsis.

Organ dysfunction codes: Organ dysfunction must be specifically named such as acute renal failure or acute respiratory failure to report the appropriate codes. If the physician does not specifically name the organ dysfunction and documents onlysevere sepsis, sepsis with evidence of organ dysfunction, or severe sepsis with elevated lactate, then coders should not assign the codes for severe sepsis. In such cases, it’s appropriate to query the physician regarding which organ dysfunction occurred during the admission.

Documentation requisites: Occasionally organ dysfunctions such as acute renal failure or acute respiratory failure are documented, but may not be documented as “due to” the sepsis; in which case, severe sepsis cannot be coded. It must be explicitly documented that organ dysfunction is due to sepsis. If the documentation is unclear, coders should query the physician and fix the issue.

SEPTIC SHOCK:

Septic shock generally refers to circulatory failure associated with severe sepsis, usually manifested by hypotension. A minimum of two codes is generally required to code septic shock cases as below:

1. A code for the underlying systemic infection.

2. Code for severe sepsis with septic shock (R65.21) OR Post procedural septic shock.

(T81.12)

Additional codes for other acute organ dysfunctions should be coded, as well. The code for septic shock can never be assigned as principal diagnosis.

Sepsis and severe sepsis with a localized infection:

Sepsis is a very serious, potentially life-threatening condition that occurs when a localized infection, like a urinary tract infection (UTI) or surgical wound infection, moves into the bloodstream. Coders must educate themselves to assign the appropriate primary and secondary diagnoses codes when both the conditions present on admission.

Present on admission: Both localized infection (e.g., pneumonia or UTI) and associated sepsis/severe sepsis.

Instructional notes: 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.

  • Primary diagnosis: the code for the systemic infection
  • Secondary diagnosis: localized infection ( pneumonia or UTI)

If the sepsis is severe, an additional code R65.2 code and any applicable codes for acute organ dysfunction should also be assigned.

Example: Patient admitted with sepsis secondary to staphylococcal pneumonia.

  • Primary diagnosis: the code for the systemic infection : A41.2
  • Secondary diagnosis: localized infection: J15.20

Present on admission: Patient admitted with a localized infection and sepsis/severe sepsis develops after admission.

Instructional notes: If the patient is admitted with a localized infection and sepsis/severe sepsis develops after admission, code the localized infection first followed by the appropriate sepsis coding as secondary codes.

  • Primary diagnosis: the code for the localized infection
  • Secondary diagnosis: sepsis or severe sepsis codes as appropriate

Example: Patient admitted for acute pyelonephritis secondary to Enterococcus. During admission, the pyelonephritis advanced to severe sepsis with acute renal failure.

  • Primary diagnosis: the code for the localized infection: N10, B95.2
  • Secondary diagnosis: severe sepsis with acute renal failure: A41.81, R65.20, N17.9

Sepsis due to a post procedural infection:

As with all post procedural complications, code assignment is based on the provider’s documentation of the relationship between the infection and the procedure.

1. First code the post procedural infection code:

  • T81.40 to T81.43 Infection following a procedure
  • O86.00 to O86.03 Infection of obstetrical surgical wound
  • T88.0 Infection following immunization
  • T80.2 Infections following infusion, transfusion, and therapeutic injection

2 Then code the systemic infection (sepsis).

Infection following a procedure: T81.40 to T81.43

1. For infections following a procedure, a code from T81.40, to T81.43 Infection following a procedure that identifies the site of the infection should be coded first, if known.

2. Assign an additional code for sepsis following a procedure T81.44

3. Use an additional code to identify the infectious agent.

4. 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.

Infection of Obstetric surgical wound: O86.00 to O86.031

1. For infections following obstetrical procedure, 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.

2. Assign an additional code for sepsis following an obstetrical procedure O86.04

3. Use an additional code to identify the infectious agent.

4. 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

Infection following infusion, transfusion, and therapeutic injection: T80.2

1. For infections following infusion, transfusion, and therapeutic injection, a code from subcategory T80.2 should be coded first.

2. Use additional code to identify the specific infection, such as sepsis A41.9

3. 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.

Infection following Immunization: T88.0

1. For infections following immunization, a code from subcategory T88.0 should be coded first.

2. Use additional code to identify the specific infection.

3. 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.

Post procedural infection and post procedural septic shock

When a post procedural infection results in post procedural septic shock, the following codes should be assigned by the coders:

1. Assign codes for sepsis due to a post procedural infection.

2. Assign code T81.12-, Post procedural septic shock.

3. Additional code(s) should be assigned for any acute organ dysfunction.

Coders should not assign code R65.21, Severe sepsis with septic shock as the code T81.12 specifically denotes post procedural septic shock.

Obstetrical Sepsis:

Coders must always remember that conditions pertaining to obstetric cases pick up the code sets from chapter 15 (Pregnancy, Childbirth, and the Puerperium (O00-O9A) and this apply to sepsis as well.

When sepsis and septic shock are complicating abortion, pregnancy, childbirth, and the puerperium, the following codes should be assigned:

1. Primary diagnosis should be the obstetrical sepsis code, O85 (Puerperal sepsis)

2. Assign additional code B95-B97 to identify infectious agent.

3. Assign additional code R65.2- to identify severe sepsis and any associated organ dysfunction.

Note: A code from category A40, Streptococcal sepsis, or A41, Other sepsis, should not be used for puerperal sepsis.

Newborn Sepsis:

Newborn sepsis is a severe infection in an infant younger than 28 days old. Codes from Chapter 16 (Certain Conditions originating in the Perinatal Period (P00-P96) are to be used for newborn cases.

Congenital or community acquired: A newborn condition may occur due to either the birth process (congenital) or community acquired. If the documentation does not indicate which it is, the default code would be the congenital and the code from chapter 16 should be reported. If the condition is community acquired, a code from chapter 16 should not be assigned. The following codes should be assigned for newborn sepsis:

  • Assign a code from category P36 – Bacterial sepsis of newborn.
  • If the P36 code includes the causal organism, an additional code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, should not be assigned.
  • If the P36 code does not include the causal organism, assign an additional code from category B96, if applicable.
  • Assign additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction.

“The content in the above article is valid at the time of posting. It may subject to changes in future years.”

References:

https://www.aappublications.org/content/36/5/26
http://decisionhealth.com/static/pdf/CPH15008_2-issue.pdf

1 Comment

  • Jaya

    March 21, 2020 2:33 pm
    Reply

    Thanks for sharing!

Leave a Reply