Sequencing the Diagnosis of Sepsis

Sepsis Sequencing

Sepsis can occur in combination with many conditions reported from other chapters within ICD-10-CM that have special sequencing considerations, most notably, Chapter 15 Pregnancy, Childbirth and the Puerperium. When the guidelines from another chapter do not take precedence, coders should follow the ICD-10-CM Official Guidelines for Coding and Reporting from Chapter 1 for sepsis, severe sepsis and septic shock.

Sepsis Due to Localized Infection

When sepsis is present on admission and due to a localized infection (not a device or post procedural), the sepsis code is sequenced first followed by the code for the localized infection. If a patient is admitted with a localized infection that progresses to sepsis after admission, the code for the localized infection is sequenced first followed by the appropriate sepsis code(s) (see ICD-10-CM coding guideline I.C.1.d.4).

Examples:

• Patient presents with fever, chills, elevated WBC, shortness of breath, cough and mental status changes. Upon admission the patient was diagnosed with possible sepsis and chest x-ray confirmed pneumonia. The patient was treated with IV antibiotics with improvement and discharged on day four of admission. The final diagnosis was sepsis due to pneumonia. In this case, since the sepsis was present on admission and due to the underlying infection of pneumonia, the coder would sequence sepsis (A41.9-Sepsis unspecified organism) as the principal diagnosis and pneumonia (J18.9-Pneumonia, unspecified organism) as a secondary diagnosis. If the sepsis and/or pneumonia were further specified as to the causative organism or type of pneumonia, coders could report more specific codes.
• Patient presents with fever, shortness of breath and cough. Upon admission the patient is diagnosed with pneumonia. The patient was treated with IV antibiotics, but their condition worsened, and the patient developed sepsis. Antibiotics were changed, and the patient improved and was discharged on day four of admission. The final diagnosis is pneumonia with sepsis. In this case, since the sepsis did not develop until after admission the localized infection of pneumonia (J18.9-Pneumonia, unspecified organism) is sequenced as the principal diagnosis followed by the diagnosis of sepsis (A41.9-Sepsis unspecified organism) as a secondary diagnosis. If it is not clear whether sepsis was present on admission, a query should be sent for clarification.
• Patient is admitted with multiple symptoms that were suggestive of sepsis. After workup and treatment, the patient was discharged with a diagnosis of sepsis due to E. coli urinary tract infection (UTI). In this case, since the sepsis was present on admission and due to E. coli UTI, then A41.5- Sepsis due to Escherichia coli is the principal diagnosis followed by the diagnosis of N39.0-Urinary tract infection, site not specified as a secondary diagnosis.
  Note, based on advice from Coding Clinic, no additional code is assigned from category B96 to identify E. coli as the causative organism for the UTI. Even though there is a “Use additional code (B95-B97), to identify infectious agent" instructional note at code N39.0, code A41.51 clearly identifies the bacteria underlying both infections, so reporting the additional code for the bacteria would be redundant. 

Sepsis Due to Post Procedural Infection

When sepsis develops secondary to a postprocedural wound infection, a complication code from T81.41-T81.43, T81.49, O86.00-O86.03, or O86.09 that identifies the site of the infection is sequenced first.

Codes for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04) are assigned as secondary codes. Use another additional code to identify the infectious agent. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.

As with all postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the infection and the procedure.

Examples:

• Patient presented with fever, chills, elevated WBC, and tachycardia with obvious left leg cellulitis due to previous removal of saphenous vein for CABG. This had been an issue for several days and was extremely red and swollen. The patient was admitted to r/o sepsis and to begin IV antibiotics. Culture of the draining left leg and blood cultures were sent to the laboratory for testing. This showed MRSA. The documentation does support that sepsis was ruled in. After six days of IV antibiotics the patient is ready for discharge. Discharge diagnosis is superficial MRSA cellulitis of left leg due to previous surgery progressing to MRSA sepsis. In this case, you would report T81.41XA Infection following a procedure, superficial incisional surgical site, initial encounter as the principal diagnosis followed by T81.44XA Sepsis following a procedure, initial encounter, A41.02 Sepsis due to MRSA and L03.116 Cellulitis of lower limb as additional codes.  

Sepsis Due to Device, Implant and Graft

Patients with devices, implants or grafts may develop sepsis due to their presence. An example is a patient who develops sepsis secondary to an indwelling catheter. The cause-and-effect relationship between sepsis and the presence of the device/implant/graft MUST be made by the physician. If this link is not made, or there is conflicting documentation, a query is necessary to clarify the cause-and-effect relationship.

The most common patients to develop sepsis due to graft/device/implant infections are those with indwelling vascular (e.g., hemodialysis, PICC) or urinary catheters. Organisms on the skin are the most common underlying cause of this type of infection, but this is not always the cause. The coder must read the documentation carefully to determine the source and cause of the infection. 

• Patient presented from nursing home with fever, elevated WBC, tachycardia and altered mental status and was admitted with a diagnosis of sepsis. During the workup it was noted that the patient had an indwelling Foley catheter. The catheter was removed and sent for culture. Urine and blood cultures were also obtained prior to starting the patient on IV antibiotics.  At the time of discharge, the patient was diagnosed with E. coli sepsis due to UTI, and E. coli UTI secondary to indwelling Foley. In this case, T83.511A Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter is reported as the principal diagnosis. A41.51 Sepsis due to Escherichia coli, and N39.0 Urinary tract infection, site not specified would be reported as additional diagnoses. There is a “Use additional code to identify infection” instructional note under T83.51-. This note directs sequencing of the complication code and the codes for sepsis and UTI. 

To view examples and to learn more, download our Sepsis Coding eBook.

References
sciencedirect.com/topics/medicine-and-dentistry/graft-infection
nytimes.com/2019/02/21/well/live/sepsis-is-a-common-cause-of-hospital-deaths.html
ICD-10-CM Official Guidelines for Coding and Reporting FY 2020
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2019: Page 17
Coding Clinic for ICD-10-CM/PCS, First Quarter 2019: Page 13-14
Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2018: Pages 22-23, 89-90
Coding Clinic for ICD-10-CM/PCS, First Quarter 2018: Page 16
Coding Clinic for ICD-10-CM/PCS, First Quarter 2015: Pages 19-20

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.