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. What is sepsis due to unspecified organism?
Symptoms Signs and symptoms of sepsis. To be diagnosed with sepsis, you must have a probable or confirmed infection and all of the following signs: Change in mental status; Systolic blood pressure — the first number in a blood pressure reading — less than or equal to 100 millimeters of mercury (mm Hg)
Several factors increase the risk of sepsis, including:
Just six months ago, 11-year-old Mark Cannon - known as 'Wee Mark' - was diagnosed with acute lymphoblastic leukaemia - a very aggressive form of blood cancer. But that was just the start of a long battle fraught with a series of major complications including sepsis, multiple seizures and even sight loss.
How do you code sepsis? 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.
Septicemia – There is NO code for septicemia in ICD-10. Instead, you're directed to a combination 'A' code for sepsis to indicate the underlying infection, such A41. 9 (Sepsis, unspecified organism) for septicemia with no further detail.
ICD-10-CM Code for Sepsis, unspecified organism A41. 9.
Sepsis is a systemic inflammatory response due to an infection. It's not necessary for blood cultures to be positive to code sepsis. Documentation issues: You can code for sepsis when the physician documents the term “sepsis.” Documentation should be consistent throughout the chart.
Urosepsis Is No Longer Coded Considered in ICD-10-CM as a nonspecific term and not associated with sepsis, the default code for this condition in ICD-9-CM (599.0 Urinary tract infection, site not specified) is not carried forward in ICD-10-CM.
Sepsis is the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death. In other words, it's your body's overactive and toxic response to an infection. Like strokes or heart attacks, sepsis is a medical emergency that requires rapid diagnosis and treatment.
According to the guidelines above, sepsis would be the appropriate principal diagnosis if it is the reason the patient is admitted, and meets the definition of principal diagnosis.
Other instances when sepsis would not be selected as the principal diagnosis, even if it was POA include the scenario where sepsis is the result of a condition which is classified as a “medical complication” (such as being due to an indwelling urinary catheter or central line.
Per protocol, Code Sepsis is activated in patients who meet two or more systemic inflammatory response syndrome (SIRS) criteria due to a suspected infection to allow for early implementation of the sepsis bundle, which includes laboratory testing, fluid resuscitation, and antibiotic administration (Figure 1).
(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.
Sepsis is a systemic inflammatory response to infection that can lead to multi-organ dysfunction, failure, and even death. Urosepsis is sepsis caused by infections of the urinary tract, including cystitis, or lower urinary tract and bladder infections, and pyelonephritis, or upper urinary tract and kidney infections.
The coding of severe sepsis with ICD-10 should include the source of infection, a UTI in this case, plus the code for severe sepsis....The ED coder would assign the following ICD-10 diagnosis codes:R65.21Severe sepsis with shockN39.0UTI, site not specifiedR30.0Dysuria4 more rows
In this case, since the sepsis was present on admission and due to E. coli UTI, then A41. 5-(Sepsis due to Escherichia coli) is the PDX followed by the diagnosis of UTI (N39. 0-Urinary tract infection, site not specified) as a SDX code.
Sepsis is also known as actinomycotic sepsis, actinomycotic septicemia, erysipelothrix sepsis, escherichia coli (E coli)septicemia, haemophilus influenzae sepsis without acute organ dysfunction, hemophilus influenza septicemia, listerial sepsis, meningococcal septicemia, methicillin resistant Staph aureus (MRSA) septicemia, methicillin sensitive Staph aureus (MSSA) septicemia, methicillin susceptible Staphylococcus aureus sepsis without acute organ dysfunction, pseudomonas septicemia, sepsis (severe bloodstream infection), sepsis due to central venous catheter, sepsis due to enterococcus, sepsis due to Erysipelothrix, sepsis due to infected central venous catheter, sepsis due to Listeria monocytogenes, sepsis due to Streptococcus agalactiae, sepsis due to Streptococcus pyogenes, sepsis due to urinary tract infection, sepsis due to UTI, sepsis related to central venous catheter, sepsis with chromobacterium septicemia, sepsis with coagulase negative staph septicemia, sepsis with enterococcal septicemia, sepsis with gonococcal septicemia, sepsis with septicemia, sepsis with staphylococcal septicemia, sepsis with Streptococcus pneumoniae septicemia, sepsis without acute organ dysfunction due to anaerobic septicemia, sepsis without acute organ dysfunction due to Chromobacterium, sepsis without acute organ dysfunction due to coagulase-negative staphylococcus, sepsis without acute organ dysfunction due to Escherichia coli, sepsis without acute organ dysfunction due to gonococcus, sepsis without acute organ dysfunction due to gram negative septicemia, sepsis without acute organ dysfunction due to gram negative septicemia final identification pending, sepsis without acute organ dysfunction due to gram positive bacteria, sepsis without acute organ dysfunction due to meningococcal septicemia, sepsis without acute organ dysfunction due to methicillin resistant Staphylococcus aureus septicemia, sepsis without acute organ dysfunction due to pneumococcal septicemia, sepsis without acute organ dysfunction due to Pseudomonas septicemia, sepsis without acute organ dysfunction due to septicemia final identification pending, sepsis without acute organ dysfunction due to Serratia septicemia, sepsis without acute organ dysfunction due to Streptococcal septicemia, sepsis wo acute organ dysfunction w anaerobic septicemia, sepsis wo acute organ dysfunction w Chromobacterium septicemia, sepsis wo acute organ dysfunction w coagulase negative Staph septicemia, sepsis wo acute organ dysfunction w E coli septicemia, sepsis wo acute organ dysfunction w Enterococcal septicemia, sepsis wo acute organ dysfunction w Gonococcal septicemia, sepsis wo acute organ dysfunction w gram neg septicemia final id pending, sepsis wo acute organ dysfunction w gram pos septicemia final id pending, sepsis wo acute organ dysfunction w Hemophilus influenza septicemia, sepsis wo acute organ dysfunction w meningococcal septicemia, sepsis wo acute organ dysfunction w MRSA septicemia, sepsis wo acute organ dysfunction w MSSA septicemia, sepsis wo acute organ dysfunction w other gram neg septicemia, sepsis wo acute organ dysfunction w other Staph septicemia, sepsis wo acute organ dysfunction w Pseudomonas septicemia, sepsis wo acute organ dysfunction w septicemia final id pending, sepsis wo acute organ dysfunction w Serratia septicemia, sepsis wo acute organ dysfunction w Staph septicemia final id pending, sepsis wo acute organ dysfunction w Strep group A septicemia, sepsis wo acute organ dysfunction w Strep group B septicemia, sepsis wo acute organ dysfunction w Strep pneumoniae septicemia, sepsis wo acute organ dysfunction w Strep septicemia, sepsis anaerobic septicemia, sepsis gram neg septicemia organism id pending, sepsis gram negative septicemia, serratia septicemia, staphlococcal septicemia, staphylococcal sepsis without acute organ dysfunction, staphylococcal sepsis without acute organ dysfunction final identification pending, streptococcal septicemia, systemic infection, and urosepsis.
Sepsis is when the body has a very severe reaction to bacteria, virus, or other germs. Chemicals that are released into the bloodstream to fight off the infection trigger inflammation throughout the body, which can be very dangerous even fatal.
995.91 is a legacy non-billable code used to specify a medical diagnosis of sepsis. This code was replaced on September 30, 2015 by its ICD-10 equivalent.
People with sepsis are usually treated in hospital intensive care units. Doctors try to treat the infection, sustain the vital organs, and prevent a drop in blood pressure. Many patients receive oxygen and intravenous fluids. Other types of treatment, such as respirators or kidney dialysis, may be necessary. Sometimes, surgery is needed to clear up an infection.
NEC "Not elsewhere classifiable" - This abbreviation in the Alphabetic Index represents "other specified". When a specific code is not available for a condition, the Alphabetic Index directs the coder to the "other specified” code in the Tabular List.
Doctors diagnose sepsis using a blood test to see if the number of white blood cells is abnormal. They also do lab tests that check for signs of infection.
The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.
NOS "Not otherwise specified" - This abbreviation is the equivalent of unspecified.
Sepsis is a serious illness. It happens when your body has an overwhelming immune response to a bacterial infection. The chemicals released into the blood to fight the infection trigger widespread inflammation. This leads to blood clots and leaky blood vessels. They cause poor blood flow, which deprives your body's organs of nutrients and oxygen. In severe cases, one or more organs fail. In the worst cases, blood pressure drops and the heart weakens, leading to septic shock.
Systemic disease associated with the presence of pathogenic microorganisms or their toxins in the blood. The presence of pathogenic microorganisms in the blood stream causing a rapidly progressing systemic reaction that may lead to shock. Symptoms include fever, chills, tachycardia, and increased respiratory rate.
The 2022 edition of ICD-10-CM A41.9 became effective on October 1, 2021.
Urosepsis . Clinical Information. (sep-sis) the presence of bacteria or their toxins in the blood or tissues. A disorder characterized by the presence of pathogenic microorganisms in the blood stream that cause a rapidly progressing systemic reaction that may lead to shock.
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.
Sepsis is a potentially life-threatening condition that occurs when the body’s response to an infection damages its own tissues. Without timely treatment, sepsis can progress rapidly and lead to tissue damage, organ failure, and then death. Proper coding of sepsis and SIRS requires the coder to understand the stages of sepsis and common documentation issues.
Sepsis is an extreme response to infection that develops when the chemicals the immune system releases into the bloodstream to fight infection cause widespread inflammation. This inflammation can lead to blood clots and leaky blood vessels, and without timely treatment, may result in organ dysfunction and then death. Severe cases of sepsis often result from a body-wide infection that spreads through the bloodstream, but sepsis can also be triggered by an infection in the lungs, stomach, kidneys, or bladder. Thus, it is not necessary for blood cultures to be positive to code sepsis (guideline I.C.1.d.1.a.i).
Severe sepsis is sepsis with acute organ dysfunction. It occurs when one or more of the body’s organs is damaged from the inflammatory response. Any organ can be affected.
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.
Septic shock refers to circulatory failure associated with severe sepsis. It is a life-threatening condition that happens when the exaggerated response to infection leads to dangerously low blood pressure (hypotension). Septic shock is a form of organ failure.
A code from ICD-10-CM code subcategory R65.2- (severe sepsis) would not be reported unless the physician has documented severe sepsis or an acute organ dysfunction;
In Chapter 1 the code range A40 – A41.9, classifies several types of bacterial sepsis but also includes “Sepsis, unspecified organism”. When assigning a code for SIRS and Severe Sepsis, Chapter 18 is where the codes are located:
In 2016, researchers and clinical experts published the consensus for a Sepsis -3 definition, stating: Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
If the organism causing the Sepsis is documented, use a code in subcategory A41 (e.g., A41.51 Sepsis due to E. coli);
We know that SEPSIS is a life-threatening condition and there has been much discussed about this subject in many clinical circles as well as in clinical coding and clinical documentation improvement (CDI). The golden rule for the HIM Coding and CDI professional is that we must have the diagnostic documentation by the provider in order to assign the ICD-10-CM code (s) and follow Official Guidelines.
A physician query may be necessary to clarify that the organ dysfunction in the record is related to the sepsis, if not documented clearly. Cryptic septic shock is another type of shock being documented.
One site stated that approximately 30% of patients with severe sepsis do not survive. Patients may develop one organ dysfunction/failure, multi-system organ failure and/or septic shock. Septic shock is severe cardiovascular dysfunction with extremely low blood pressure and hypoperfusion that does not respond to intravenous fluids.
In Part 4 we will discuss clinical indicators needed to report the diagnosis of sepsis as well as when to query the physician for support of the diagnosis.
In Part 2, we focused on sepsis sequencing. In Part 3, we are going to focus on documentation needed to report the diagnosis of severe sepsis.
Take-Away Points: Severe sepsis is associated with at least one acute organ dysfunction/failure. There are two codes for severe sepsis which indicate whether septic shock is present or not. Approximately 30% of people diagnosed with severe sepsis will expire.
For coders, if the physician has documented severe sepsis, linked an acute organ dysfunction/failure to sepsis or the ICD-10-CM Index to Diseases directs the coder to the code for severe sepsis, it may be coded.
These patients have severe lactic acidosis (4.0 mM/L or greater) and clinical signs of shock. The blood pressure may be normal in patients with cryptic septic shock. ALL patients should have a serum lactate measured that present with signs of sepsis.
Sepsis associated with organ dysfunction distant from the site of infection.
The 2022 edition of ICD-10-CM R65.20 became effective on October 1, 2021.