Difference between ICD 10 code for Urosepsis and Sepsis

In ICD 10 coding sepsis is little complicated. Coding of sepsis involves use of two or more codes. There is separate coding guideline only for Sepsis where we can learn how to easily code sepsis. It is infectious and can lead to organ failure if not take care at right time. Now, I am here just to remove confusion about ICD 10 code for urosepsis and sepsis. Now, both are defines separately in ICD 10. Urosepsis has no icd 10 diagnosis code. Sepsis has an specific ICD 10 code. It should not be confused with sepsis just because of word sepsis in Urosepsis.

Read also : Learn about ICD9 and ICD10 differences

ICD 10 code difference for urosepsis & Sepsis

Urosepsis is actually coded  urinary tract infection (599.0) in ICD 9. But, in ICD 10 is has no diagnosis code for urosepsis. ICD 10 does not consider urosepsis as disease or disorder. Hence urosepsis should not be coded in ICD 10, only sepsis should be reported with ICD 10 diagnosis codes. For coding sepsis follow using A41.9 ICD 10 code.

A41.9  Sepsis, unspecified organism 

ICD 10 for urosepsis : no code assigned

Coding for Severe Sepsis

Sepsis with organ failure leads to severe sepsis.

Severe sepsis needs three ICD 10 codes. First code denotes the infection, second code with severe sepsis and third code for organ failure.

R65.2 Severe sepsis

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)

R65.20 Severe sepsis without septic shock

R65.21 Severe sepsis with septic shock

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 intravascular coagulopathy [DIC] (D65)
encephalopathy (metabolic) (septic) (G93.41)
hepatic failure (K72.0-)

If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2, Severe sepsis.  An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code.  If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.

If severe sepsis is present on admission, and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List.  A code from subcategory R65.2 can never be assigned as a principal diagnosis.

When severe sepsis develops during an encounter (it was not present on admission), the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as secondary diagnoses.

Severe sepsis may be present on admission, but the diagnosis may not be confirmed until sometime after admission.  If the documentation is not clear whether severe sepsis was present on admission, the provider should be queried.