Streptococcus pneumoniae, or pneumococcus, is an encapsulated Gram-positive bacterium that is the major cause of bacteremia and upper respiratory infections (eg, otitis media and sinusitis) in children and a common cause of serious invasive infections.
R78.81ICD-10 code R78. 81 for Bacteremia is a medical classification as listed by WHO under the range - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified .
ICD-10 code J15. 9 for Unspecified bacterial pneumonia is a medical classification as listed by WHO under the range - Diseases of the respiratory system .
Pneumonia, unspecifiedICD-10 code: J18. 9 Pneumonia, unspecified | gesund.bund.de.
If septic shock is documented, A41. 9 and R65. 21 can be coded. It is important to note that the adjective septic in other instances, such as septic encephalopathy or septic emboli, does not mean that A41.
Clinically, the physician may not be differentiating the diagnoses as two different things, even though coding does. Now, bacteremia is the principal diagnosis, it won't change your DRG, though it could certainly affect quality concerns and medical necessity.
Pneumonia due to other specified bacteria The 2022 edition of ICD-10-CM J15. 8 became effective on October 1, 2021.
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.
ICD-10 Code for Pneumonitis due to inhalation of food and vomit- J69. 0- Codify by AAPC.
Postobstructive pneumonia is defined as an infection of lung parenchyma secondary to bronchial obstruction (4). It is often associated with lung malignancy (see Figure 1).
01.
9 for Sepsis, unspecified organism is a medical classification as listed by WHO under the range - Certain infectious and parasitic diseases .
Bacteremia – Code R78. 81 (Bacteremia).
Bacteremia is the presence of bacteria in the blood, hence a microbiological finding. Sepsis is a clinical diagnosis needing further specification regarding focus of infection and etiologic pathogen, whereupon clinicians, epidemiologists and microbiologists apply different definitions and terminology.
The 2022 edition of ICD-10-CM B95.3 became effective on October 1, 2021.
B95 Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere. B95.0 Streptococcus, group A, as the cause of diseases classified elsewhere. B95.1 Streptococcus, group B, as the cause of diseases classified elsewhere. B95.2 Enterococcus as the cause of diseases classified elsewhere.
Sepsis can be caused by fungi, candida, or viruses, as well. It is important to use the Alphabetic Index to select the appropriate code for the systemic infection. For example, if a patient is diagnosed with candidal sepsis due to a candida UTI, you would report B37.7 Candidal sepsis for the principal diagnosis and B37.49 Other urogenital candidiasis for the secondary diagnosis. Do not select a code from A40.- through A41.9.
A 79-year-old patient presented to the emergency department (ED) with shortness of breath and was admitted with a diagnosis of community-acquired pneumonia. The vital signs and lab work done in the ED revealed that the patient had a fever, tachypnea, and leukocytosis, and the chest X-ray showed infiltrates. The sputum culture was positive for Pseudomonas aeruginosa. The patient had a six-day length of stay. The discharge diagnoses were Pseudomonas pneumonia, lactic acidosis, asthma exacerbation, hypoxemia, and chronic bronchitis. “Possible sepsis” was documented in the consulting physician’s note only.
Coding tips: Only one code is needed to report sepsis without organ dysfunction. Most sepsis codes are listed in A40.- through A41.9. If a causal organism is specified, then use the code for sepsis naming the specific organism. Per AHA Coding Clinic® (Vol. 5, No. 1, p. 16), when sepsis is linked to an infection with an organism, assign the combination code for sepsis including the organism. For example, sepsis due to E. coli UTI can be coded as A41.51 and N39.0.
For instance, if sepsis, pneumonia, and acute renal failure due to dehydration are documented, the code for severe sepsis may not be assigned because the acute renal failure is not stated as due to or associated with sepsis. If the documentation is unclear, query the physician.
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. However, a query for sepsis may be appropriate according to AHA Coding Clinic® (Vol. 1, No. 3, p. 4).
A systemic infection can occur as a complication of a procedure or due to a device, implant, or graft. This includes systemic infections due to postoperative wound infections, infusions, transfusions, therapeutic injections, implanted devices, and transplants.
Sepsis, systemic inflammatory response syndrome (SIRS), and septicemia have historically been difficult to code. Changing terminology, evolving definitions, and guideline updates over the past 20 years have created confusion with coding sepsis.
The presence of viable bacteria circulating in the blood. Fever, chills, tachycardia, and tachypnea are common acute manifestations of bacteremia. The majority of cases are seen in already hospitalized patients, most of whom have underlying diseases or procedures which render their bloodstreams susceptible to invasion.
It is often transient and of no consequence; however, sustained bacteremia may lead to widespread infection and sepsis. Systemic Inflammatory Response Syndrome (SIRS) Establishes a clinical response to a nonspecific condition of either infectious or noninfectious origin.