Sepsis Documentation and Coding Guidelines
Sepsis coding can be difficult, especially with the need for coders to be more knowledgeable on the clinical indicators of Sepsis, Severe Sepsis, and Septic Shock. First, coders need to understand the definition of Sepsis:
- Sepsis is the presence in the tissues of harmful bacteria and their toxins, particularly through an infection of a wound.
- Severe Sepsis is Sepsis plus either failure of an essential system in the body or inadequate blood flow to parts of the body due to an infection.
- Septic Shock is life-threatening low blood pressure (shock) due to Sepsis.
The clinical indicators in the provider documentation must support the assignment of codes for Sepsis or Severe Sepsis.
For Sepsis, the documentation criteria is:
- Fever (temperature greater than 100.4 degrees) or hypothermia (temperature less than 96.8 degrees)
- Leukocytosis (white blood cell count greater than 12,000) or leukopenia (white blood cell count less than 4000 or greater than 10% bands)
- Tachycardia (greater 90 beats per minute)
- Tachypnea (respiratory rate greater than 20 breaths per minute or a pCO2 of less than 32 mmHg)
For Severe Sepsis the criteria is:
- Evidence of reduced organ perfusion or evidence of organ dysfunction
For Septic Shock:
- Systolic blood pressure of less than 90 mmHg or a 40% drop in mmHg from previous normal blood pressure
Now that we have the definitions of the various Septic diagnoses, and the clinical criteria that must be met in order to validate Sepsis, let’s identify the correct ICD-10 code assignments.
Per ICD-10 Official Coding Guidelines, if the patient is admitted with a localized infection and Sepsis or Severe Sepsis, the code for the systemic infection should be assigned first, followed by a code for the localized infection. 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.
Sepsis is coded with only one code A41.9 for unspecified organism, or 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 a minimum of 2 codes; a code for the underlying systemic infection and a code from category R65.2 Severe Sepsis. Codes for the acute organ dysfunction should also be assigned. (Note that R65.2 is unacceptable as a PDx and must be sequenced after a code for the underlying systemic infection). Septic Shock follows the accurate coding for Severe Sepsis in subcategory R65.2 and the 5th character will be a 1 to indicate Severe Sepsis with Septic Shock.