ICD – 10 Guidelines Chapter-1 Sepsis and severe sepsis with a localized infection
ICD – 10 guidelines Chapter-1 Sepsis and severe sepsis with a localized infection
4) Sepsis and severe sepsis with a localized infection
- If patient admitted with sepsis and severe sepsis and a local infection such as pneumonia and cellulitis
- First code systemic infection is coded
- Second localized infection is coded
- Third severe sepsis is coded.
- If patient admitted for local infection and there is no severe sepsis until admission and developed later then
- First local infection is coded
- Second sepsis , severe sepsis.
Scenario:
- A patient is admitted because of sepsis ,severe sepsis and pneumonia.
- How to code?
- Pdx: A41.9
- Sdx: j18.9
- Sdx:r65.20
5) Sepsis due to a postprocedural infection.
- (a) Documentation of causal relationship.
- Because of post procedural complication there should be documentation of relationship between sepsis and infection .
- (b) Sepsis due to a postprocedural infection
- First infection code is coded such as
- T80.2, Infections following infusion, transfusion, and therapeutic injection,
- T81.4, Infection following a procedure
- T88.0, Infection following immunization
- O86.0, Infection of obstetric surgical wound
- Second the severe sepsis
- Third is infection if it is there along with organ dysfunction is also coded.
Scenario:
- A patient had immunization procedure two days before today because of procedure he had infection of sepsis.
- How to code?
- Pdx:t88.0
- Sdx:A41.9
(c) Postprocedural infection and postprocedural septic shock
- If a postprocedural infection has occurred and has resulted in severe sepsis.
- First will code infection.
- Second infection and third severe sepsis.
- If a postprocedural infection has resulted in postprocedural septic shock.
- First code T81.4, Infection following a procedure,
- Second t81.12 Postprocedural septic shock
- Third systemic infection code.
6) Sepsis and severe sepsis associated with a noninfectious process (condition)
- If non infectious condition such as burns and serious injury leads to infection i.e sepsis and severe sepsis and in the documentation infection is associated with non infectious condition.
- First code non infectious condition.
- Second the infection.
- Third severe sepsis if present along with any organ failure.
Note:
- R65.1, Systemic inflammatory response syndrome (SIRS) of non-infectious origin, for these cases.
- If infection meets as pdx first code infection following non infectious condition
- When both meets a pdx we can code any one as pdx.
- When non infectious leads to infection and severe sepsis. First code non infect then infection and severe sepsis don’t code r65.1 Systemic inflammatory response syndrome (SIRS) of noninfectious origin.
Scenario:
- Patient admitted for burn which resulted in sepsis and severe sepsis.
- How to code?
- Pdx: t30.0
- Sdx: a41.9
- Sdx: r65.20
- 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.
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