Sepsis can also be caused by viral or fungal infections, although bacterial infections are by far the most common cause. Causes of sepsis Sepsis can be triggered by an infection in any part of the body. The most common sites of infection leading to sepsis are the lungs, urinary tract, tummy (abdomen) and pelvis.
Left untreated, gangrene may progress to a serious blood infection called sepsis. Sepsis may cause complications including organ failure, extremely low blood pressure, changes in mental status, shock and death.
When sepsis is present on admission and due to a localized infection (not a device or post procedural), the sepsis code is sequenced first followed by the code for the localized infection. Patient presents with fever, chills, elevated WBC, shortness of breath, cough and mental status changes.
• 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. Note: ‘A’ codes for Sepsis in ICD-10 include both the underlying infection
pneumoniae] as the cause of diseases classified elsewhere. B96. 1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
Klebsiella pneumoniae is a rare sepsis-causing bacteria, but it is well known for its severe outcomes with high mortality6,7).
ICD-10-CM Code for Sepsis, unspecified organism A41. 9.
81.
Klebsiella [kleb−see−ell−uh] is a type of Gram-negative bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis.
Klebsiella pneumoniae is second to Escherichia coli the most common gram-negative pathogen associated with a wide spectrum of infections, such as urinary tract infection (UTI), pneumonia, intra-abdominal infection, bloodstream infection (BSI), meningitis and pyogenic liver abscess (PLA) [1–4].
81, Bacteremia, is a symptom code with an Exclude1 note stating it can't be used with sepsis and that additional documentation related to the cause of the infection, i.e., gram-negative bacteria, salmonella, etc., would be needed for correct code assignment.
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.
Overview. Sepsis is a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues. When the infection-fighting processes turn on the body, they cause organs to function poorly and abnormally. Sepsis may progress to septic shock.
A41. 51 (Sepsis due to Escherichia coli), and N39. 0 (Urinary tract infection, site not specified) would be reported as additional diagnoses.
The ED coder would assign the following ICD-10 diagnosis codes:R65.21Severe sepsis with shockN39.0UTI, site not specifiedR30.0DysuriaR50.81Fever presenting with conditions classified elsewhereN17.9Acute kidney failure, unspecified2 more rows
ICD-10-CM Code for Enterococcus as the cause of diseases classified elsewhere B95. 2.
But klebsiella pneumoniae can be dangerous if they get into other parts of your body, especially if you're already sick. They can turn into “superbugs” that are almost impossible to fight with common antibiotics. The germs can give you pneumonia, infect your wound or blood, and cause other serious problems.
Klebsiella pneumonia is a necrotizing process with a predilection for debilitated people. It has a high mortality rate of approximately 50% even with antimicrobial therapy. The mortality rate approaches 100% for persons with alcoholism and bacteremia.
Klebsiella bacteria are mostly spread through person-to-person contact. Less commonly, they are spread by contamination in the environment. As with other healthcare-associated infections, the bacteria can be spread in a health care setting via the contaminated hands of health care workers.
A doctor may prescribe a combination of antibiotics. One study observed lower mortality rates in people with bacteremia from K. pneumoniae who had received a combination of the antibiotics colistin, meropenem, and tigecycline.
Post-procedural Sepsis and Sepsis Due to a Device, Implant, or Graft. 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 wound infection, infusions, transfusions, therapeutic injections, implanted devices, and transplants.
For instance, if severe 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.
Bacteremia . Bacteremia is a lab finding of infectious organisms in the blood. The patient has no clinical signs of sepsis or SIRS. Bacteremia may be transient, or may lead to sepsis. When a patient’s blood cultures are positive and not believed to be a contaminant, the patient is usually treated with antibiotics.
If the patient has severe sepsis, add R65.2- with the codes for specific organ dysfunctions.
You must query the physician when the term “sepsis syndrome” is documented as a final diagnosis. Know when to Query. Sepsis is a complicated condition to code, and it is often necessary to query the physician to code the case correctly.
Documentation issues: You can code for sepsis when the physician documents the term “sepsis.”. Documentation should be consistent throughout the chart. Occasionally, during an extended length of stay, sepsis may resolve quickly and the discharging doctor may not include the diagnosis of sepsis on the discharge summary.
term “sepsis” must also be documented to code a systemic infection. This is a major change from ICD-9-CM. If the term “sepsis” is not documented with “SIRS” when it’s due to a localized infection, you must ask for clarification from the physician.
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.
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.
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).
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.
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.
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.
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).
Sepsis means potentially fatal condition caused when the body responses to the presence of infection or organisms in the blood. Choose the appropriate “A” code from the alphabetical index to indicate sepsis with type of infection or causal organism, if the doctor documents “Sepsis with type of infection or causal organism”.
Severe sepsis with septic shock: Septic shock means severe sepsis associated with circulatory failure. Assign the code in the same above format (severe sepsis) as it represents the type of acute organ dysfunction. But here, we will report a code R65.21 (which indicates severe sepsis with septic shock) instead of R65.20 (severe sepsis).
If the doctor documents “Sepsis” but the type of infection or causal organism is not specified, then will assign the A41.9 code, which indicates Sepsis, unspecified organism.