SEPSIS/SIRS ICD-10-CM CODING Updated official Coding Guidelines with 50 Case Studies and Rationale For AAPC CPC and AHIMA CCS Exam LIVE Work Examples. MEDESUN Medical Coding Academy FY-2022
Bacteremia
Septicemi a
Sepsis
Septic Shock Severe Sepsis
SIRS
Sepsis WHEN TO Query – Clinical Indicators •Hypotension •Elevated lactic acid •Metabolic acidosis •Altered mental status/confusion •Lethargy/weakness •Multi-organ failure •Coagulopathy •Positive blood cultures
Sepsis is when organ dysfunction occurs due to infection. It could be due to a local infection like pneumonia; it could also be due to a systemic infection like bacteremia. But any time an infection causes organ dysfunction diffusely in the body, it’s called sepsis. It’s a specific type of reaction to infection. Organ Dysfunction occurs due to many reasons.. Sepsis is one of the reason, hence provider has to document the connection that patient has Organ Dysfunction due to sepsis.
As per Payer- Imp Slide Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Insurance company requires the medical record to meet the following guidelines for sepsis: •Documented infection, which can be presumed or confirmed; and •Presence of acute organ dysfunction or failure due to the infection or sepsis; and •Based on the causative organism (known or presumed), appropriate pharmacotherapy is initiated.
Septic Shock A subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities substantially increase mortality.” Septic shock represents a more severe illness with a much higher likelihood of death
Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score The baseline SOFA score can be assumed to be zero in patients not known to have preexisting organ dysfunction. A higher SOFA score is associated with an increased probability of mortality. Organ dysfunction can be represented by an increase in the SOFA score of two points or more The score is based on six organ system scores, one each for respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems
The clinical criteria for qSOFA include: •Respiratory rate ≥22/min •Altered mentation •Systolic blood pressure ≤100 mm Hg
•Severe sepsis requires at least 2 ICD-10-CM codes; a code for the underlying systemic infection and a code from category R65.2 Severe Sepsis; you should also assign a code(s) for the acute organ dysfunction if documented; •Codes R65.20 and R65.21 as not acceptable as Principal diagnosis and must be sequenced after a code for the underlying systemic infection; •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; •Currently, when there is documentation of Severe sepsis, there should be evidence of organ dysfunction or perfusion
Patient presents with fever, chills, elevated WBC, shortness of breath, cough and mental status changes. Upon admission the patient is documented with possible sepsis and chest x-ray confirmed pneumonia. Patient was treated with IV antibiotics with improvement and was able to be discharged on day four of admission. 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 (A41.9Sepsis unspecified organism) as the PDX and pneumonia (J18.9-Pneumonia, unspecified organism) as a SDX code. If the sepsis and/or pneumonia were further specified, coders would report the more specific codes.
Patient is admitted with multiple symptoms that were suggestive of sepsis. After workup and treatment, the patient was discharged with a diagnosis of sepsis due to E. coli urinary tract infection (UTI). 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. Note, in this case no additional code was added for the E. coli bacteria causing the UTI, even though there is an instructional note, since the bacteria is clearly reported in code A41.51. Since the bacteria is responsible for both conditions, reporting the additional code for the bacteria would be redundant.
Patient presented with fever, chills, elevated WBC, and tachycardia with obvious left leg cellulitis due to previous removal of saphenous vein for CABG. This had been an issue for several days and was extremely red and swollen. The patient was admitted to r/o sepsis and to begin IV antibiotics. Culture of the draining left leg and blood cultures were sent to the laboratory for testing. This did show MRSA. The documentation does support that sepsis was ruled in. After six days of IV antibiotics the patient is ready for discharge. Discharge diagnosis is MRSA left leg superficial skin cellulitis due to previous surgery developing MRSA sepsis. In this case, you would report T81.41XA (Infection following a procedure, superficial incisional surgical site, initial encounter) as the PDX followed by T81.44XA (Sepsis following a procedure, initial encounter), A41.02 (Sepsis due to MRSA) and L03.116 (Cellulitis of lower limb) as additional SDX. Per the OCG FY 2020, T81.41XA is first and then additional codes for the sepsis.
Patient presented with fever, chills, elevated WBC, and tachycardia with obvious left leg cellulitis due to previous removal of saphenous vein for CABG. This had been an issue for several days and was extremely red and swollen. The patient was admitted to r/o sepsis and to begin IV antibiotics. Culture of the draining left leg and blood cultures were sent to the laboratory for testing. This did show MRSA. The documentation does support that sepsis was ruled in. After six days of IV antibiotics the patient is ready for discharge. Discharge diagnosis is MRSA left leg superficial skin cellulitis due to previous surgery developing MRSA sepsis. In this case, you would report T81.41XA (Infection following a procedure, superficial incisional surgical site, initial encounter) as the PDX followed by T81.44XA (Sepsis following a procedure, initial encounter), A41.02 (Sepsis due to MRSA) and L03.116 (Cellulitis of lower limb) as additional SDX. Per the OCG FY 2020, T81.41XA is first and then additional codes for the sepsis.
Sepsis Due to Device, Implant and Graft Patients with devices, implants or grafts often develop sepsis due to the presence of the device. The link MUST be made by the physician. If this link is not made, or there is conflicting documentation, a query is necessary to clarify the cause and effect relationship. When looking in the ICD-10-CM alphabetic index, there are entries under Sepsis—due to for arterial graft to ventricular shunt. The most common graft/device/implant infections are found in hemodialysis, vascular, and urinary patients. This typically occurs due to skin organisms, but this is not always the cause. The coder must read the documentation carefully to help in determining the type of device, implant or graft that is infected.
Sepsis Due to Device, Implant and Graft
Patient presented from nursing home with fever, elevated WBC, tachycardia and altered mental status and was admitted with the diagnosis of sepsis. During the workup it was documented that the patient had an indwelling Foley catheter for reasons unknown to the physician. The catheter was removed and sent for culture as well as urine and blood cultures obtained prior to starting the patient on IV antibiotics. At the time of discharge, the patient is documented to have E. coli sepsis due to UTI, and E. coli UTI secondary to indwelling Foley. In this case, T83.511A (Infection and Inflammatory reaction due to indwelling urethral catheter, initial encounter) is reported as the PDX. A41.51 (Sepsis due to Escherichia coli), and N39.0 (Urinary tract infection, site not specified) would be reported as additional diagnoses. There are instructional notes under T83.51- to use additional code to identify infection. In the OCG, coders are instructed to report the complication code first, followed by the code for sepsis.
•Dialysis patient presents after staff noticed a fever, chills and altered mental status during their scheduled outpatient dialysis session. Work up did reveal extremely high WBC on labs after admission and the diagnosis of sepsis was made. Infectious disease saw the patient and recommended removal of the arteriovenous (AV) graft that the patient had been using for dialysis. The patient will remain on IV antibiotics for 6 weeks and then removal will be scheduled. The discharge diagnosis given is sepsis due to AV graft infection. •In this case, the PDX will be T82.7XXA (Infection and Inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter). An additional code of A41.9 (Sepsis, unspecified organism) would be reported since the infection did progress to sepsis. There are instructional notes under T82.7- to use additional code to identify infection.
IMPORTANT POINTSSepsis 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. Septicemia: Presence of pathological microorganisms in the blood stream such as virus, bacteria, fungus, toxins due to infection or trauma. There is NO code for septicemia in ICD-10-CM is same as Sepsis code. Per Index, you are directed to code is A41.9
IMPORTANT POINTS-
IMPORTANT POINTSSevere Sepsis: The coding of severe sepsis requires a minimum of two codes. The first code will identify the underlying systemic infection, followed by a code from subcategory R65.2, severe sepsis. Report either ICD-10-CM code R65.21 (severe sepsis without septic shock) or R65.22 (severe sepsis with septic shock) in addition to the sepsis code (A40.- or A41.-). Code first A41Example: Severe Sepsis due to E coli with Acute Hepatic Failure First choose the correct code for the underlying infection, such as A41.51 (Sepsis due to Escherichia coli [E. coli]), then code the severe sepsis, such as R65.20 (Severe sepsis without septic shock) and then assign an additional code for the organ dysfunction it’s causing, such as K72.00 (Acute and subacute hepatic failure without coma). The ICD-10-CM Codes are A45.51 R65.20 K72.00
IMPORTANT POINTSSeptic Shock: Septic shock represents circulatory failure with severe sepsis.a type of acute organ dysfunction and the presence of severe sepsis. Code first underlying infection ( A41.XX), then R65.21, then organ failure. Example: Respiratory failure due to Septic shock caused by E coli Code first the underlying infection (for example A41.51, Sepsis due to Escherichia coli [E. coli]), then code the severe sepsis combination code that indicates the presence of septic shock (R65.21, Severe sepsis with septic shock) and lastly code the associated organ failure (such as J96.00, Acute respiratory failure, unspecified whether with hypoxia or hypercapnia).
IMPORTANT POINTSREMEMBER: The code for the systemic infection should be assigned first, followed by a code for the localized infection (for example pneumonia); If the patient is admitted with a localized infection, and develops Sepsis after admission, a code for the localized infection is assigned first, followed by a code for the Sepsis or Severe sepsis; If the organism causing the Sepsis is documented, use a code in subcategory A41 (e.g., A41.51 Sepsis due to E. coli); Severe sepsis requires at least 2 ICD-10-CM codes; a code for the underlying systemic infection and a code from category R65.2 Severe Sepsis; you should also assign a code(s) for the acute organ dysfunction if documented;
IMPORTANT POINTSCodes R65.20 and R65.21 as not acceptable as Principal diagnosis and must be sequenced after a code for the underlying systemic infection; 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; Currently, when there is documentation of Severe sepsis, there should be evidence of organ dysfunction or perfusion Example: A 39-year-old woman is admitted with high fever, leukocytosis, malaise, and myalgias. Blood and urine cultures taken on admission are positive for Escherichia coli (E. coli). The patient is diagnosed with septicemia and urinary tract infection due to E. coli. Correct coding is: A41.51 Sepsis due to Escherichia coli [E. coli] N39.0
Urosepsis and Sepsis Syndrome The term urosepsis is no longer indexed in ICD-10-CM. The Alphabetic Index instructs you to “code to condition.” When urosepsis is documented and the patient meets sepsis criteria, the coder must query the physician (guideline I.C.1.d.a.ii).
•The Clinician providing all the information on the patient’s diagnoses and treatment dated with signature. •The Clinical Coder translating that information into the appropriate coded format to reflect the patient’s hospital stay. REMEMBER-Entire patient record is the source document
Clinical Notes Hospital information systems Discharge Summary Operation/Theatre information Histology reports Sepsis Form
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