Coding Septicemia, Systemic Inflammatory Response Syndrome (SIRS), Sepsis Flashcards
Septicemia 1a: SIRS, Septicemia, and Sepsis
The terms septicemia and sepsis are often used interchangeablly by providers, however they are not considered synonymous terms. The following descriptions are provided for reference but do not preclude querying the provider for clarification about terms used in the documentation.
Septicemia
Generally refers to a systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bateria, viruses, fungi or other organisms.
Systemic Inflammatory Response Syndrome (SIRS)
generally refers to the systemic response to infection, trauma/burns, or other insult (such as cancer) with symptoms including fever tachycardia, tachypnea, and leukocytosis.
Sepsis
generally refers to SIRS due to infection
Severe Sepsis
generally refers to sepsis with associated acute organ dysfunction.
Septicemia 1b: The coding of SIRS, sepsis and severe sepsis
requires a minimum of 2 codes: a code for the underlying cause (such as infection or trauma) and a code from subcategory 995.9 Systemic inflammatory response syndrome (SIRS).
(i) The code for the underlying cause (such as infection or trauma) must be sequenced before the code from subcategory 995.9 Systemic inflammatory response syndrome (SIRS)
(ii) Sepsis and severe sepsis require a code for the systemic infection (038.xx, 112.5 etc) and either code 995.91, Sepsis, or 995.92, Severe Sepsis. If the causal organism is not documented, assign code 038.9, Unspecified septicemia.
(iii) Severe sepsis required additonal code(s) for the associated acute organ dysfunction(s)
(iv) If a patient has spsis with multiple organ dysfunctions, follow the instructions for coding severe sepsis.
(v) Either the term sepsis or SIRS must be documented to assign a code from subvategory 995.9.
(vi) See section I.C.17.g), Injury and poisoning for information regarding SIRS due to trauma/burns and other non-infectious processes.
Septicemia 1c: Querying provider
Due to the complex nature of sepsis and sever sepsis, some cases may require querying the provider prior to assignment of the codes.
Septicemia 2a: Sepsis and severe sepsis as pricipal diagnosis
If sepsis or severe sepsis is present on admission, and meets the definition of principal diagnosis, the systemic infection code (e.g., 038.xx, 112.5, etc) should be assigned as the principal diagnosis, followed by code 995.91, Sepsis, or 995.92, Severe Sepsis, as required by the seequencing rules in the Tabular List.
Codes from subategory 995.9 can never be assigned as a princpal diagnosis. A code should also be assigned from any localized infection, if present.
See section I.C.1.b.10 if the diagnosis is due to a postprocedural infection.
Septicemia 2b: Sepsis and sever sepsis as secondary diagnoses
When sepsis or severe sepsis develops during the encounter (it was not present on admission). the systemic infection code and code 995.91 (sepsis) or 995.92 (severe sepsis) should be assigned as secondary diagnoses.
Septicemia 2c: Documentation unclear as to whether sepsis or sever sepsis is present on admission
Sepsis or severe sepsis may be present on admission but the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether the sepsis or severe sepsis was present on admission, the privider should be queried.
Septicemia 3: Sepsis/SIRS with Localized Infection
If the reason for admission is both sepsis, severe sepsis, or SIRS and a localized infection, such as pneumonia or cellulitis, a code for the sytemic infection (038.xx, 112.5 etc.) should be assigned first, then code 995.91 or 995.92, followed by the code for the localized infection.
If the patient is admitted with a localized infection, such as pneumnoa, and sepsis/SIRS doesn’t develop after admission, see guideline I.C.1.b.2.b).
If the localized infection is postprocedural, see Section I.C.1.b.10 for guielines related to sepsis due to postprocedural infection.
Septicemia 4: Bacterial Sepsis and Septicemia
In most cases, it will be a code from category 038, Septicemia, that will be used in conjunction with a code from subvategory 995.9 such as the following:
(a) steptococcal sepsis: if the documentation is the record states streptococcal septicemia, and code 995.91 should be used, in that sequence.
(b) Steptococcal septicemia: if the documentation states steptoccal septicemia, only code 038.0 should be assigned, however, the provider should be queried whether the patient has sepsis, an infection with SIRS.
Septicemia 5: Acute organ dysfunction that is not clearly associated with the sepsis
If a patient has sepsis and and acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the spesis, DO NOT assigned Code 995.92, Severe sepsis.
An acute organ dysfunction MUST be assoicated with the sepsis in order to assign the sever sepsis code. If the documenation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condidion, query the provider.
Septicemia 6a: Septic Shock Sequencing
Septic shock generally refers to circulatory failure associated with sever sepsis, and, therefore, it represents a type of acute organ dysfunction.
For cases of septic shock, the code for the systemic infection should be sequenced first, followed by codes 995.92 (severe sepsis) and 985.52 (Septic shock) or 998.02 (postoperative septic shock). Any additonal codes for other acute organi dysfunctions should also be assigned.
As noted in the sequencing instructions in the Tabular List, the code for septic shock CANNOT be assigned as a principal diagnosis.
Septicemia 6b: Septic shock w/out documentation of sever sepsis
Since septic shock indicates the presence of severe sepsis, code 995.92 (severe sepsis) can be assigned with code 785.52 (septic shock), or 998.02 (postoperative shock, septic) even if the term severe sepsis is not documented in the record.
