Coding Septicemia, SIRS, Sepsis, Severe Sepsis & Septic Shock in ICD-9 CM & ICD-10 CM Part I

1. NOTE: Remember sepsis and septicemia is different.
 Septicemia is defined as a systemic disease with the presence of
pathological microorganisms or toxins in the blood, such as
bacteria, viruses, fungi or other organisms.
 Bacterial infections are usually coded as a type of septicemia.
 Sepsis is a whole body inflammation due to an immune response
caused by an infection (SIRS due to infection).
 Both can result in SIRS.
 Sepsis can result in acute organ(s) dysfunction and septic shock.
 If documentation states septicemia; used the main term septicemia
when locating the correct code.
 Query physician when indicators point to sepsis over septicemia.
WHAT’S THE DIFFERENCE?
WHAT TO EXPECT
1 What’s the Difference?
2 When & How Should I
Query the Physician?
3 How Many Codes Should I
Use?
4 Requests for Coding Topics
February 2015
Volume 2 Issue 2
By Cynthia Brown, MBA, RHIT, CCS
www.cyntcodinghealthinformationservices.com
CCHIS, P.O. Box 3019, Decatur, GA 30031 404-992-8984
http://www.cyntcodinghealthinformationservices.com
Cynthia@cyntcodinghealthinformationservices.com [phone]
CODING YESTERDAY’S NOMENCLATURE TODAY®
SEPTICEMIA, SYSTEMIC INFLAMMATORY RESPONSE
SYNDROME (SIRS), SEPSIS, SEVERE SEPSIS & SEPTIC
SHOCK,
ICD-9 CM & ICD-10 CM CODING PART I
CODING NEWSLETTER FOR HEALTHCARE
CODING PROFESSIONALS

2. Page 2 Coding Yesterday’s Nomenclature Today
WHEN
 When the physician documents “urosepsis” to find out if he means a
simple urinary tract infection or sepsis. Especially when coding in ICD-10
because “urosepsis” is no longer found in the nomenclature.
 When the physician documents “sepsis syndrome” to find out if he means
severe sepsis.
 When it is not clear whether “sepsis or severe sepsis” was present on
admission.
 When the documentation does not link the localized infection to the
sepsis, severe sepsis, or SIRS.
 When the documentation does not specify if the infection is due to a line
or catheter.
 When the documentation does not show the relationship between the
infection and the procedure.
 When the total clinical picture and treatment is indicative of sepsis
despite the negative blood cultures.
 When there are indications of an underlying cause when admitted with
symptoms of sepsis.
 When documentation is not clear whether the acute organ dysfunction is
related to sepsis or another medical condition.
HOW
 Make sure to use departmentally approved “Query” forms.
 Make sure the “Query” form is not leading in the response the physician
is being asked to give.
 Make sure the “Query” form does not ask the physician to make
assumptions; but that the response is validated by documentation.
 Make sure the “Query” form indicates the financial impact of the query.
 Make sure the “Query” does not question the physician’s medical
judgment which is achieved by requiring a “yes” or “no” response when
the query concerns Present on Admission (POA).
REMINDER: Patients can have sepsis or severe sepsis that is caused by a
“noninfectious” condition such as a trauma or burn. Recovery Audit
Contractors (RAC) are targeting DRG 871-872 for review; therefore
incomplete documentation and inaccurate coding can mean a loss in revenue.
www.cyntcodinghealthinformationservices.com
“Not sure…then Query the
Physician”
Total Clinical Picture &
Treatment is Indicative
of Sepsis
When &How Should I Query the Physician?

3. Coding Yesterday’s Nomenclature Today
HOW MANY CODES SHOULD I USE?
ICD-9 CM ICD-10 CM
Septicemia: Requires 2 codes (the
code for the type of septicemia and
SIRS)
Septicemia (not meaning sepsis):
Requires 2 codes (Code 1st
T81.4;
O75.3; O03-O07, O08.0; T88.0;
T80.2- and the code 041.9).
Unspecified SIRS: Requires 2
codes (1st
the underlying condition
then 995.90)
Unspecified SIRS: Requires 2
codes (1st
the underlying condition
then R65.10)
Sepsis, SIRS w/o organ
dysfunction: Requires 2 codes: 1st
underlying infection; then 995.91
Sepsis, SIRS w/o organ
dysfunction: Requires 2 codes:
(Code to infection and R65.10).
Severe Sepsis: Requires 3 codes:
(1st
underlying infection; then
995.92; code type of organ failure).
Severe Sepsis: Requires 3 codes:
(1st
underlying infection; then
R65.20 or R65.21; code type of
organ failure).
SIRS due to noninfectious process
w/o organ dysfunction: Requires 2
codes: (1st
underlying condition;
then 995.93).
SIRS due to noninfectious process
w/o organ dysfunction: Requires 2
codes: (1st
underlying condition;
then R65.10).
SIRS due to noninfectious process
with organ dysfunction: Requires 3
codes: (1st
underlying condition or
trauma; then 995.94; then code to
identify organ failure).
SIRS due to noninfectious process
with organ dysfunction: Requires 3
codes: (1st
underlying condition or
trauma; then R65.11; then code to
identify organ failure).
Septic Shock: Requires 4 codes:
(1st
underlying infection or trauma;
then 995.92 or 995.94 or 998.02;
then code to identify organ
dysfunction; then 785.52).
Septic Shock: Requires 3 codes:
(1st
underlying infection or trauma;
then R65.21 or T81.12; 995.94;
then code to identify organ
dysfunction; then).
REMEMBER: Sequence 999.31 first when coding septicemia or sepsis due
to central venous catheter followed by the appropriate code(s) for
septicemia or sepsis.
www.cyntcodinghealthinformationservices.com
AHIMA approved ICD-10 CM/PCS
Trainer
ALL THINGS CODING®
“Accurate and
complete coding is a
must in today’s
economically
challenged healthcare
environment.”

4. Page 4 Coding Yesterday’s Nomenclature Today
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