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.

Read also: Coding Guide for Hypothyroidism ICD 10 codes

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

Read also: Top common mistakes done in ICD 10 coding

Coding tip for Sepsis

The diagnosis of sepsis is primarily classified to the A41 code grouping. The “code first” instructional note lists postprocedural sepsis (T81.4-); sepsis during labor (O75.3); sepsis following abortion, ectopic, or molar pregnancy (O03–O07 and O08.0); sepsis following immunization (T88.0); and sepsis following infusion or therapeutic injection (T80.2-).

The Excludes1 note lists bacteremia NOS, neonatal sepsis, puerperal sepsis, and streptococcal sepsis.

If the reason for admission is both sepsis/severe sepsis and a localized infection, such as pneumonia or cellulitis, code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis. If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn’t develop until after admission, the localized infection should be assigned first, followed by the appropriate sepsis/severe sepsis codes. The COVID-19 guidelines also reference this guideline when sequencing sepsis related to COVID-19.

For infections following infusion, transfusion, therapeutic injection, or immunization, a code from subcategory T80.2, Infections following infusion, transfusion, and therapeutic injection, or code T88.0-, Infection following immunization, should be coded first, followed by the code for the specific infection. If the patient has severe sepsis, the appropriate code from subcategory R65.2, Severe sepsis, should also be assigned, with the additional codes(s) for any acute organ dysfunction.

Other related Sepsis ICD 10 codes

The ICD codes for sepsis occurred 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.

Impact of Sepsis on Reimbursement

A 79-year-old patient presented to the emergency department (ED) with shortness of breath and was admitted with a diagnosis of commu- nity-acquired pneumonia. The vital signs and lab work done in the ED revealed that the patient had a fever, tachypnea, and leukocytosis, and the chest X-ray showed infiltrates. The sputum culture was positive for Pseudomonas aeruginosa. The patient had a six-day length of stay. The discharge diagnoses were Pseudomonas pneumonia, lactic acidosis, asthma exacerbation, hypoxemia, and chronic bronchitis. “Possible sepsis” was documented in the consulting physician’s note only.

As the documentation stands, the ICD-10 codes are:

J15.1 Pneumonia due to Pseudomonas

J45.901 Unspecified asthma with (acute exacerbation) (Note: J45.901 is designated as a complication and comorbidity by CMS.)

E87.2 Acidosis (Note: E87.2 is designated as a complication and comorbidity by CMS.)

R09.02 Hypoxemia

J42 Unspecified chronic bronchitis

Medicare Severity Diagnosis Related Group (MS-DRG):

178, $12,916.47

Now, let’s see what would happen if the coder queried the physi- cian about a sepsis diagnosis and the provider confirmed that the patient had sepsis. The chart would then be coded as:

A41.9 Sepsis, unspecified organism

J45.901 E87.2 J15.1 R09.02 J42

MS-DRG:871, $19,682.62

The difference in reimbursement between the two scenarios for this hospital encounter is $6,766.15.

Coding tips: Per ICD-10-CM guideline I.C.1.d.4, if a patient is admitted with localized infection and sepsis or severe sepsis, assign the code for the systemic infection (i.e., sepsis) first, followed by a code for the localized infection when sepsis meets the definition of a principal diagnosis. If the patient is admitted with a localized infec- tion and the patient does not develop sepsis or severe sepsis until after the admission, the localized infection is coded first, followed by the appropriate codes for sepsis or severe sepsis, if applicable.

According to AHA Coding Clinic® (Vol. 1, No. 3, p. 4), when a patient has SIRS and a localized infection, sepsis can no longer be coded and an ICD-10-CM code for sepsis cannot be assigned unless the physician specifically documents sepsis. In the ICD-10- CM Alphabetic Index, under Syndrome/systemic inflammatory response, the only options are for “of non-infectious origin” without (R65.10Systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction) or with acute organ dysfunc- tion codes (R65.11 Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction).

Example: A patient is admitted with pneumonia and acute hypoxic respiratory failure. On day three, the patient worsens and becomes hypotensive with fever and tachycardia and is diagnosed with sepsis, septic shock, and acute renal failure. On the discharge summary, pneumonia is documented as the principal diagnosis. Correct coding would be:

J18.9 Pneumonia, unspecified organism J96.01 Acute respiratory failure with hypoxia A41.9

N17.9 Acute kidney failure, unspecified

R65.21 Severe sepsis with septic shock

Bacteremia

Bacteremia is a microbiological lab finding of bacteria in the blood. When a patient is diagnosed solely with bacteremia, it means that they are not showing any clinical signs of sepsis or SIRS. Bacteremia may be transient, or it can lead to sepsis. When a patient’s blood cultures are positive, but the physician does not believe it to be a contaminant, the patient is treated with antibiotics.

Documentation issues: The ICD-10-CM code for bacteremia is R78.81 Bacteremia. If the patient has bacteremia with sepsis, the Alphabetic Index directs the coder to “see Sepsis.” When both bacteremia and sepsis are documented, code sepsis only.

Coding tips: According to ICD-10-CM guideline I.B.4, if bacteremia is associated with a local infection, code first the local infection, followed by the code for bacteremia, and then the infec- tious organism. Note that R78.81 is a sign-and-symptom code from Chapter 18 so it cannot be coded as the principal diagnosis when a definitive diagnosis has been documented.

Example: A 79-year-old patient is admitted with dizziness and dysuria. A urine sample is collected on admission and is positive for Klebsiella pneumoniae. The blood sample, taken on admission, is also positive for Klebsiella. The doctor lists: Urinary tract infection (UTI) due to Klebsiella, bacteremia due to Klebsiella. Correct coding is:

R78.81

N39.0 Urinary tract infection, site not specified

B96.1 Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere

Septicemia

Septicemia, also known as blood poisoning, is a serious infection of the blood. Usually, it is caused by the presence of bacteria or toxins in the blood, but it can also be caused by fungal, parasitic, or viral infections. In contrast to bacteremia, where the patient is asymptomatic, septicemia causes symptoms and is a clinical diagnosis. Septicemia is not just a transient lab finding; the patient has symptoms, and the condition warrants inpatient admission with antibiotics and supportive treatment.

Documentation issues: Septicemia is rarely a term physicians document. To reflect this shift in terminology, when you look up the term septicemia in the ICD-10-CM Alphabetic Index, you are told to “seeSepsis.” Under the entry for sepsis in ICD-10-CM are the various causative organisms and septic conditions.

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

Systemic Inflammatory Response Syndrome

SIRS is an inflammatory state affecting the whole body. It is an exaggerated defense response of the body to a noxious stressor, such as infection or trauma, that triggers an acute inflamma- tory reaction, which may progress and result in the formation of blood clots, impaired fibrinolysis, and organ failure. Patients with SIRS will have two or more of the following symptoms: tachycardia, tachypnea, leukocytosis or leukopenia, and fever or (rarely) hypothermia.

SIRS Criteria Table:

• Temperature > 38° C or < 36° C (> 4° or < 96.8° F)
• Heart rate > 90 beats/min
• Respiratory rate > 20 breaths/min
• White blood cells > 12,000 cell/mm3 or < 4,000 cells/mm3

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.

Coding tips: SIRS can be due to noninfectious causes or infec- tious causes. When SIRS is due to a noninfectious process, code first the noninfectious process, followed by the code for SIRS. If organ dysfunction is documented, code also R65.11 and the code(s) for the specific organ dysfunction. When it is unclear whether the acute organ dysfunction is related to SIRS, query the provider (guideline I.C.18.g). Code R65.10 or R65.11 as the principal diagnosis only in the rare instance when the physician documents that they are unable to

determine the underlying cause of SIRS.

Example: A 27-year-old patient is admitted with fever, tachy- pnea, and a high lipase level. The patient is diagnosed with SIRS due to acute pancreatitis. Code this as:

K85.90 Acute pancreatitis without necrosis or infection, unspecified

R65.10

Viral Sepsis

Sepsis due to a virus is not found as a subterm in the Alphabetic Index. This has raised many questions when coding sepsis due to the influenza and COVID-19 viruses. AHA Coding Clinic® (Vol. 3, No. 3, p. 8) advises using A41.89 Other specified sepsis for sepsis due to viral infections even though this code is found in the Other Bacterial Diseases section (A30-A49) of Chapter 1. When sepsis oc- curs with COVID-19, follow guidelines I.C.1.d.1-4 for sequencing. Example: A 59-year-old male presents with generalized muscle aches, coughing, and fever and is diagnosed with sepsis due to acute

viral bronchitis due to influenza A. Report these codes:

A41.89

J10.1 Influenza due to other identified influenza virus with other respiratory manifestations

J20.8 Acute bronchitis due to other specified organisms

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 postoperative wound infections, infusions, transfusions, therapeutic injections, implanted devices, and transplants

Documentation issues: The physician must document the cause-and-effect relationship between the infection and the pro- cedure or device (guidelines I.B.16 and I.C.1.d.5.a). Common cause-and-effect relational words and phrases include “due to,” “associated with,” “related to,” “attributed to,” and “secondary to.” If the documentation isn’t clear as to the relationship, query the physician. Occasionally, the physician will state “infected PICC line” or “infected spinal hardware.” These are examples of when a cause-and-effect relationship between the implant/device and the infection is implied by the adjective “infected,” and can be coded as a complication.

A query may be necessary when “sepsis due to complicated UTI” is documented on a chart. In this statement, it is unclear what is complicating the UTI. It could be the patient’s medical condition, or it could be an indwelling Foley catheter. It is important that the cause of sepsis be accurately captured because when a complication code is sequenced first, the case will no longer fall under the sepsis MS-DRG and reimbursement will be impacted.

Coding tips: When sepsis is due to a procedural complication, sequence the complication code first, followed by the code for the specific infection. If the patient has severe sepsis, code R65.2- along with the codes for each organ dysfunction. If the exact causative organism is known, code for the infectious agent (guidelines I.C.1.5.b-c).

Obstetrical Sepsis

When sepsis and septic shock are complicating abortion, pregnancy, childbirth, and/or the puerperium, sequence the obstetrical code first, followed by a code for the specific type of infection. Per guideline I.C.15.j, if the patient has severe sepsis, code R65.2- with the codes for each organ dysfunction. Also, if the specific causative organism is known, code for the infectious agent. According to guideline I.C.15.k, code A41.- Other sepsis should not be added for puerperal sepsis.

Guideline I.C.1.d.5.b states that if sepsis occurs due to an obstetric procedure, first assign O86.04 Sepsis following an obstetrical procedure,followed by the codes for sepsis. When documented, report additional codes for severe sepsis and any organ dysfunction.

Newborn Sepsis

When a newborn is diagnosed with sepsis, assign a code from category P36 Bacterial sepsis of newborn. According to guideline I.C.16.f, if a newborn is documented as having sepsis without documentation of whether it is congenital or community-acquired, the default is congenital, and a code from P36 is assigned. Most of the codes in category P36 include the causative organism, so an additional code for the infectious organism should not be assigned. If the P36 code does not identify the specific organism, however, an additional code for the organism can be assigned.

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)

Hope, you have cleared all your confusion regarding coding ICD 10 code for sepsis. Share your valuable comments in the comments box section.