Coding Tip: Viral Sepsis—Finally Answered
Kim Carrier, RHIT, CDIP, CCS, CCS‑P
Director of Coding Quality
AHIMA Approved ICD‑10‑CM/PCS
Viral Sepsis is defined as a systemic infection due to the presence of a virus entering the blood.
Sepsis is typically caused by bacteria entering the blood but can be due to virus, fungi or parasites as well. Common sources of infection that result in sepsis are the lungs, the abdomen, and the urinary tract. About 50% of all sepsis cases start as an infection in the lungs. No definitive cause of sepsis is found in one-third to one-half of the patients with sepsis. Approximately 20-35% of patients with severe sepsis and 30-70% of patients with septic shock die. In the US sepsis affects approximately 3 in 1,000 people and severe sepsis is responsible for more than 200,000 deaths per year. Age, conditions that weaken the immune system such as cancer, diabetes, or the absence of a spleen; and major trauma and burns are common sepsis risk factors and increase a person’s susceptibility to developing sepsis.
At this time, assign A41.89, other specified sepsis, and B97.89, other viral agents as the cause of diseases classified elsewhere for a diagnosis of viral sepsis. ICD-10-CM does not provide a specific code for viral sepsis and A41.89 is the best available option. The specific type of viral infection would also be coded as an additional diagnosis in place of B97.89 if applicable. If the specific type of viral infection is unknown then the coder would report B97.89 to provide further specificity and show that the sepsis is due to a viral infection. Don’t forget to report additional codes for severe sepsis and any organ dysfunction documented if applicable to your case.
There are several coding questions/scenarios in the recent Coding Clinic, Third Quarter 2016. Please refer to this document for further guidance/explanation on specific coding scenarios regarding sepsis and viral sepsis reporting.
Here are just a couple of examples that are common for coders to see:
- Patient presents with fever, tachycardia and severe cough. Patient is admitted for presumed sepsis. On discharge, the physician documents that the patient has sepsis secondary to viral syndrome. In this case, A41.89 would be sequenced as the PDX for the viral sepsis (other specified sepsis) and B34.9 for the viral syndrome as an additional diagnosis.
- Patient presents very ill with possible flu. The patient does test positive for influenza A and sepsis is diagnosed on admission. The discharge diagnosis is viral sepsis secondary to influenza A/acute bronchitis. In this case, A41.89 would be sequenced as the PDX for the viral sepsis (other specified sepsis) and J10.1 for the influenza due to other identified influenza virus with other respiratory manifestations and J20.8 for the acute bronchitis due to other specified organism.
Coding Clinic, Third Quarter 2016, Page: 9-14
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.