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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.
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