Basics of Sepsis ICD-10 coding
When we talk about ICD 10 codes, we are talking about specificity in each aspect. The ICD 10 codes are arranged in such a way that coders should be able to code the perfect and specific diagnosis code.
Now, ICD 10 codes cannot be used as single code like CPT codes to represent a word procedure. ICD 10 has increased in number compared to ICD 9 because of using multiple diagnosis codes when required. Yes, their are many scenarios where we have to use 2 or more ICD 10 codes to give more specific information about diagnosis codes.
For example, pregnancy complication ‘O’ codes require a Z3A category codes for specific weeks of gestation. Similarly, their are many combination codes for hypertension, diabetes which require multiple codes. But, today we will learn about coding spesis codes. Medical coders find it very difficult to code sepsis because of it different variations. Sepsis, septicemia, SIRS, Severe sepsis and sepstic shock are the main terms used in diagnosis coding in medical coding.
Sepsis
Sepsis is a Systemic disease associated with the presence and persistence of streptococcal pathogenic microorganisms and their toxins in the blood. Sepsis is also called Septicemia.
ICD 10 codes for Sepsis
Generalized sepsis codes should be reported from A40 & A41 series ICD 10 codes. When sepsis with specified organism is documented code the specific code, if unspecified report A41.9 ICD 10 code.
A41.9 Sepsis, unspecified organism
SIRS with or without infectious origin
Systemic inflammatory response syndrome (SIRS) generally refers to the systemic response to infection, trauma/burns, or other insult (such as cancer), with symptoms including fever, tachycardia, tachypnea, and leukocytosis. SIRS are of non-infectious origin. Do not get confuse with severe sepsis because sepsis always means an infection, while SIRS can be with or without infection.
SIRS with infectious origin should be coded with severe sepsis as per ICD 10 coding guidelines.
Sever Sepsis Coding Guidelines
Severe sepsis is more harmful than sepsis or viral sepsis because it is associated with an acute or mutiple organ dysfunction. But, while coding severe sepsis the documentation must support that acute organ dyfunction is related to sepsis. If the acute organ dysfucntion is not relation to sepsis than we should not report the severe sepsis code, we will only code the normal sepsis ICD 10 code.
Severe sepsis requires two additional codes along with severe sepsis ICD 10 code R65.20-R65.21. Two coding notes will be given above Sever sepsis ICD 10 code. Severe severe can also be called as:
- Infection with associated acute organ dysfunction
- Sepsis with acute organ dysfunction
- Sepsis with multiple organ dysfunction
- Systemic inflammatory response syndrome due to infectious process with acute organ dysfunction
First ICD 10 code will be from below list.
Code first underlying infection, such as:
infection following a procedure (T81.4-)
infections following infusion, transfusion and therapeutic injection (T80.2-)
puerperal sepsis (O85)
sepsis following complete or unspecified spontaneous abortion (O03.87)
sepsis following ectopic and molar pregnancy (O08.82)
sepsis following incomplete spontaneous abortion (O03.37)
sepsis following (induced) termination of pregnancy (O04.87)
sepsis NOS (A41.9)
The “code first” note means code first, if present. The code first instruction should be followed only when the underlying conditions are present or documented, if not it is not applicable. This instructional note is intended for conditions that have both an underlying etiology and manifestation, and indicates the proper sequencing order: etiology first, followed by the manifestation.
After coding the infection, the coders have to code a severe sepsis ICD 10 code R65.20-R65.21 followed by the acute organ dysfunction code from below list.
R65.20 Severe sepsis without septic shock
R65.21 Severe sepsis with septic shock
Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction.
Use additional code to identify specific acute organ dysfunction, such as:
acute kidney failure (N17.-)
acute respiratory failure (J96.0-)
critical illness myopathy (G72.81)
critical illness polyneuropathy (G62.81)
disseminated encephalopathy (metabolic) (septic) (G93.41)
hepatic failure (K72.0-)
The above list of organ failure will specify the type of organ failure occured due to sepsis.
Sepsis due to device, implant or graft
Other related Sepsis ICD 10 codes
The ICD codes for sepsis occured due to presence of a device, implant or graft should be reported with T85.79 series codes.
T85.79 infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts
Sepsis can occur following a surgery procedure, such postprocedural infection have to be reported with ICD 10 T81.4 series codes.
T81.4 Infection following a procedure
Wound abscess following a procedure
Sepsis complicated pregnancy , Puerperium, childbirth & obortion
Coding for sepsis in pregnancy period requires multiple codes. The O code will be primary for coding pregnancy complication due to sepsis followed by the specified sepsis ICD 10 codes.
For Puerperal sepsis , assign O85 as primary code followed by the causal organism code from category B95-B96, Bacterial infections in conditions classified elsewhere. Do not use A40 or A41 series codes along with puerperal sepsis. In required, use severe sepsis (R65.2-) codes and any associated acute organ dysfunction.
Urosepsis
The term “urosepsis” is a nonspecific term and should not be considered synonymous with sepsis.
In Short all the Sespis related ICD 10 codes
Only Sepsis: A40 & A41 series codes
SIRS (Non-infectious) : R65.10 & R65.11 (followed by a acute organ dysfunction code)
Severe Sepsis or SIRS with Infection: R65.20 & R65.21 (followed by a acute organ dysfunction code)
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