233 Physicians and coders may be familiar with the codes and guidelines for reporting sepsis using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Reporting sepsis with International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is different but perhaps simpler. The following is a review of the ICD-10-CM codes and guidelines for reporting septicemia, sepsis, and systemic inflammatory response syndrome (SIRS). ICD-9-CM Review ICD-9-CM requires a minimum of 2 codes to report sepsis. The first code identifies the septicemia or systemic infection (eg, 038.9) and the second identifies the SIRS due to an infectious process such as sepsis (995.91) or severe sepsis (995.92). Likewise, for newborn sepsis, ICD-9-CM requires 2 codes. Code 771.81, septicemia (sepsis) of the newborn, is reported first, followed by a code from category 041 identifying a bacterial infection in conditions classified elsewhere and of unspecified site. When applicable, severe sepsis (995.92) and any acute organ dysfunction should be reported as additional diagnoses. SIRS due to a noninfectious process such as trauma is reported with a code for the underlying cause (eg, trauma) followed by a code for SIRS due to noninfectious process without organ failure (995.93) or with organ failure (995.94). Moving to ICD-10-CM First, you will find that in the alphabetic index, the term septicemia is indexed to code A41.9 with an additional entry instructing to see the term sepsis if septicemia is intended to mean sepsis or SIRS due to an infectious process. Code A41.9 is used to report sepsis due to an unspecified organism. This is generally equivalent to ICD-9-CM code 038.9, unspecified septicemia. Coding Tip: Clinical evidence of sepsis is sufficient to support a diagnosis of sepsis. Negative or inconclusive blood cultures do not prohibit reporting this diagnosis when clinically indicated by a physician or other qualified health care professional. Coders are instructed to consult the physician when documentation is unclear. In ICD-10-CM, 2 codes are not always required. For instance, code A41.1 is used to report coagulase-negative staphylococcus sepsis. No additional code for SIRS due to infection is necessary. However, additional codes may be reported to identify severe sepsis with septic shock (R65.20) or without septic shock (R65.21), any organ failure, or a coexisting localized infection such as pneumonia. Coding Tip: Acute organ dysfunction must be linked to the sepsis in the documentation for coders to assign a code for severe sepsis. When applicable, additional codes are used to identify severe sepsis (R65.2-) and any associated acute organ dysfunction. A code from subcategory R65.2, severe sepsis, should not be assigned unless severe sepsis or a sepsis- associated acute organ dysfunction is documented. Appendix B-5 Coding for Sepsis (continued on page 234)
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