Watch for these changes in coding of sepsis

By Judy Monestime  bio

In Chapter 1 of ICD-10, Certain Infectious and Parasitic Diseases (A00-B99), is organized similar to ICD-9. While the overall chapter is similar to ICD-9, some categories and subcategories titles have changed along with terminology.

For example:

Urosepsis

Another change is the deletion of the term “urosepsis” condition and code. In ICD-9-CM, if urosepsis is the only term documented, then only code 599.0. Urinary tract infection should be assigned based on the default for the term in the index. In ICD-10-CM, there is no default code for “urosepsis” in the Alphabetic Index. If the provider documents this condition, further clarification should be sought prior to coding.

Septicemia

The term “septicemia” is not used in ICD-10-CM code descriptions. The definitions in the ICD-9-CM guidelines for sepsis, septicemia, SIRS, and severe sepsis are not found in ICD-10. When indexing septicemia in ICD-10-CM, the coder is led to code A41.9, Sepsis, unspecified organism.

Septic shock

In ICD-9-CM, if a patient has septic shock, the code for severe sepsis is assigned along with the code for septic shock. In ICD-10-CM, there are combination codes for severe sepsis with septic shock and severe sepsis without septic shock.

The chapter includes the following sections:

• A00-A09, Intestinal infectious diseases
• A15-A19, Tuberculosis
• A20-A28, Certain zoonotic bacterial diseases
• A30-A49, Other bacterial diseases
• A50-A64, Infections with a predominantly sexual mode of transmission
• A65-A69, Other spirochetal diseases
• A70-A74, Other diseases caused by chlamydiae
• A75-A79, Rickettsioses
• A80-A89, Viral and prion infections of the central nervous system
• A90-A99, Arthropod-borne viral fevers and viral hemorrhagic fevers
• B00-B09, Viral infections characterized by skin and mucous membrane lesions
• B10, Other human herpesviruses
• B15-B19, Viral hepatitis
• B20, Human immunodeficiency virus [HIV] disease
• B25-B34, Other viral diseases
• B35-B49, Mycoses
• B50-B64, Protozoal diseases
• B65-B83, Helminthiases
• B85-B89, Pediculosis, acariasis and other infestations
• B90-B94, Sequelae of infectious and parasitic diseases
• B95-B97, Bacterial and viral infectious agents
• B99, Other infectious diseases

When coding sepsis it is important to review the coding guidelines and the notes at the category of ICD-10 CM. According to the ICD-10-CM Official Guidelines for Coding and Reporting:

Coding sepsis and severe 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.

The coding of severe sepsis requires a minimum of two codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is 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.

Coding 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.

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. 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.

Let’s practice! How do you code the following encounter?

A 58-year-old male was taken to the ER after being found conscious with markedly abnormal vital signs—a fever of over 101 degrees Fahrenheit. The final diagnosis, provided by the doctor, was severe sepsis and gram-negative sepsis. What is the correct diagnosis code(s)?

A41.50, Gram-negative sepsis, unspecified R65.20, Severe sepsis without septic shock

Rationale: 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. A code from subcategory R65.2 can never be assigned as a principal diagnosis.

Judy Monestime, MBA, CDIP, CPC, is an AHIMA-approved ICD-10-CM/PCS trainer.