ICD – 10 Guidelines Chapter-1 Sepsis, Severe Sepsis, and Septic Shock

ICD – 10 Guidelines Chapter-1 Sepsis, Severe Sepsis, and Septic Shock

 

Sepsis, Severe Sepsis, and Septic Shock

  • Sepsis: It’s a severe infection caused by particular organism.
  • Severe sepsis: it’s a severe infection by organism and leads to organ dysfunction
  • Severe sepsis with septic shock: it’s a severe infection caused by organism refers to circulatory failure and is a form of organ dysfunction associated with sepsis and cannot occur in the absence of severe sepsis.

 

  • Coding of Sepsis and Severe Sepsis

(a) 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.

Scenario:

Patient is coming with sepsis infection of unspecified

organism how to code?

Pdx: A41.9

 

A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented.

  • (i) Negative or inconclusive blood cultures and sepsis Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition; however, the provider should be queried.

 

  • ii) Urosepsis The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.

 

 

Sepsis with organ dysfunction If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction (MOD), follow the instructions for coding severe sepsis.

 

  • Acute organ dysfunction that is not clearly associated with the sepsis If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2, Severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.

(b) Severe sepsis

  • The coding of severe sepsis requires a minimum of 2 codes:
  • First a code for the underlying systemic infection,
  • Second 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.

 

Scenario:

  • Patient coming to hospital because of severe sepsis associated with hepatic failure

How to code?

Pdx: A41.9

Sdx: r65.20

Sdx: K72.90

  • 3) 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 in the Tabular List. 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.

Septic shock

(a) Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction

(b) Minimum 3 codes

Sequencing of septic shock

  • First systemic infection code
  • Second a code R65.21, Severe sepsis with septic shock or code T81.12, Post procedural 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.
  • Scenario:

A person with septic shock and acute respiratory failure

has come to hospital  for evaluation.

How to code ?

Pdx:  A41.9

SDX: R65.21

SDX:j96.00

 

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