Part 2: Sepsis Series | Sequencing the Diagnosis of Sepsis
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
As discussed in Part 1 of this series, sepsis is a common diagnosis for coders, however is oftentimes difficult to know how to sequence the diagnosis in ICD-10-CM. In Part 2, we are going to focus on sequencing of sepsis when the diagnosis is clearly documented. Later in the series we will look at what to do when the diagnosis is not clearly documented.
Sepsis can be caused by many different infections, and some of those are in other chapters within ICD-10-CM and have special sequencing instructions. Without the diagnosis of sepsis falling into one of those chapters, coders should follow the ICD-10-CM Official Guidelines for Coding and Reporting of sepsis, severe sepsis and septic shock.
Sepsis Due to Localized Infection
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. 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 (A41.9-Sepsis 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 presents with fever, chills, elevated WBC, shortness of breath, cough and mental status changes. Upon admission the patient is documented with confirmed pneumonia. Patient was treated with IV antibiotics without improvement and the patient developed sepsis. Antibiotics were changed and the patient improved and was able to be discharged on day four of admission. The final diagnosis is pneumonia with sepsis. In this case, since the sepsis was not present on admission the localized infection of pneumonia (J18.9-Pneumonia, unspecified organism) is sequenced as the PDX followed by the diagnosis of sepsis (A41.9-Sepsis unspecified organism) as a SDX code. If it is not clear that the sepsis was or was not present on admission, a query should be sent for clarification.
- 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.
Sepsis Due to Post Procedural Infection
When sepsis is due to intraoperative or post procedural complications, a code from Chapter 19 within ICD-10-CM is sequenced first, followed by a code for the specific complication if applicable. The exceptions to this are when the infection/sepsis is obstetrical and a code from Chapter 15 within ICD-10-CM would be reported first.
- 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 presents with fever, chills, tachycardia and shortness of breath. She is noted to be 34 weeks pregnant. She is examined by OB in the ED and the baby appears to be fine but she does appear to have pneumonia of the right lung. Patient is admitted for IV antibiotics and monitoring of her pregnancy. After three days of IV antibiotics, she is well enough to discharge home and continue oral antibiotics for five more days. The final discharge diagnoses are: 1. Pneumonia in 34 weeks pregnant female; 2. Sepsis on admission due to pneumonia. In this case, O98.813 (Other maternal infectious and parasitic disease complicating pregnancy, third trimester) would be reported as the PDX. O99.513 (Disease of the respiratory system complicating pregnancy, third trimester), A41.9 (Sepsis, unspecified organism), J18.9 (Pneumonia, unspecified organism) and Z3A.34 (34 weeks gestation of pregnancy) would be reported as SDX codes. There are instructional notes within ICD-10-CM Index and OCG that state a code from Chapter 15: Pregnancy, Childbirth, and the Puerperium to sequence first, and codes from other chapters may be used in addition to specify the condition.
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.
- 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.
- Patient presents to the ED with fever and not feeling well. Workup in the ED showed that the patient had tachycardia of 112, high fever, and not making sense when speaking. Patient was admitted with suspected sepsis due to central venous catheter that was being used for hemodialysis and also to r/o stroke. Workup did rule out the diagnosis of stroke but the patient was found to have positive blood cultures for Streptococcal pneumoniae. The plan was long term antibiotics and change of hemodialysis catheter. The patient was discharged with the diagnosis of sepsis due to infected hemodialysis central venous catheter. In this case, T80.211A (Bloodstream infection due to central venous catheter, initial episode) would be reported as the PDX, followed by A40.3 (Sepsis due to Streptococcus pneumoniae) as a SDX. There are instructional notes under T80.2- to use additional code to identify the infection.
There are so many different reasons that may cause a patient to have sepsis, and there is no way to list all of those in this coding tidbit. Use of the OCG and Coding Clinic advice are necessary when coding sepsis and complications that may be the reason the patient develops sepsis.
In Coding Clinic for ICD-10-CM/PCS, Third Quarter 2019, coders are instructed to use the general PDX selection guidelines when there are multiple causes documented that are causing sepsis. If the conditions that are responsible for the diagnosis of sepsis are equally treated, and meet the definition of PDX, and there are no other sequencing direction, any of the diagnoses may sequenced first.
Be on the lookout for Part 3 of this series, as we will discuss and learn about needed documentation and coding for severe sepsis.
ICD-10-CM Official Guidelines for Coding and Reporting FY 2020
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2019: Page 17
Coding Clinic for ICD-10-CM/PCS, First Quarter 2019: Page 13-14
Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2018: Pages 22-23, 89-90
Coding Clinic for ICD-10-CM/PCS, First Quarter 2018: Page 16
Coding Clinic for ICD-10-CM/PCS, First Quarter 2015: Pages 19-20
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
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