Documentation issues: When SIRS is documented with an inflammatory condition, such as pancreatitis, the inflammatory condition should be sequenced first, followed by the code for SIRS, R65. 1-. When SIRS is documented with an infectious source, for instance, “SIRS due to pneumonia,” only code pneumonia.
10 for Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction is a medical classification as listed by WHO under the range - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified .
Coding sepsis requires a minimum of two codes: a code for the systemic infection (e.g., 038. xx) and the code 995.91, SIRS due to infectious process without organ dysfunction. If no causal organism is documented within the medical record, query the physician or assign code 038.9, Unspecified septicemia.
The final diagnosis is sepsis due to pneumonia. In this case, since the sepsis was present on admission and due to the underlying infection of pneumonia, the coder would sequence sepsis (A41. 9-Sepsis unspecified organism) as the PDX and pneumonia (J18. 9-Pneumonia, unspecified organism) as a SDX code.
Sepsis is a systemic response to infection. It is identical to SIRS, except that it must result specifically from infection rather than from any of the noninfectious insults that may also cause SIRS (see the image below).
Coding sepsis requires a minimum of two codes: a code for the systemic infection (e.g., 038. xx) and the code 995.91, SIRS due to infectious process without organ dysfunction. If no causal organism is documented within the medical record, query the physician or assign code 038.9, Unspecified septicemia.
Sepsis is the systemic response to infection and is defined as the presence of SIRS in addition to a documented or presumed infection. Severe sepsis meets the aforementioned criteria and is associated with organ dysfunction, hypoperfusion, or hypotension.
According to coding guidelines, the code for SIRS (995.90 to 995.94) should never be sequenced as a principal diagnosis. If SIRS is caused by an infection, coding rules require septicemia (038. x) to be listed first. If SIRS is caused by a noninfectious process, then that condition would be listed first.
A serious condition in which there is inflammation throughout the whole body. It may be caused by a severe bacterial infection (sepsis), trauma, or pancreatitis. It is marked by fast heart rate, low blood pressure, low or high body temperature, and low or high white blood cell count.
Sepsis is a complication that happens when your body tries to fight off an infection, be it pneumonia, a urinary tract infection or something like a gastrointestinal infection. The immune system goes into overdrive, releasing chemicals into the bloodstream to fight the infection.
The code for septic shock cannot be assigned as a principal diagnosis. For septic shock, the code for the underlying infection should be sequenced first, followed by code R65. 21, Severe sepsis with septic shock or code T81.
9: Fever, unspecified.
Sepsis as Principal Diagnosis Is sepsis always sequenced as the principal diagnosis when it is present on admission? Some may say yes, because after all, that's what is stated in the official coding guidelines. However, my answer to this question is no, not always.
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.
(Septic shock cannot occur without sepsis and severe sepsis being present). You would need to add codes for the underlying condition (local infection) as well as codes for the organ dysfunction resulting from the sepsis that support the presence of severe sepsis.