234 When reporting newborn sepsis, codes in category P36 are assigned. Combination codes may allow for reporting of newborn sepsis due to a specified organism with a single code such as P36.4, newborn sepsis due to Escherichia coli. However, when reporting conditions such as newborn sepsis due to Haemophilus influenzae, 2 codes are required. Code P36.8, other bacterial sepsis of newborn, is reported first, followed by code B96.3, H influenzae as the cause of diseases classified elsewhere. Codes in categories B95–B97 are used to identify the infecting organism when the infectious organism is not included in the code descriptor. It is not necessary to report codes from categories B95–B97 when the infec- tious organism is included in a code descriptor for the infection (eg, P36.8). Coding Tip: If a neonate is documented as having sepsis without documentation of congenital or community acquired, the default is congenital and a code from category P36 should be assigned. Post-procedural Sepsis As with all post-procedural complications, code assignment is based on the physician’s documentation of the relationship between the infection and procedure. Post-procedural sepsis is reported with specific codes, with most requiring a seventh character to identify the episode of care. For instance, when a newborn is diagnosed with sepsis due to a central line–associated bloodstream infection, code T80.211A, initial encounter for bloodstream infection due to central venous catheter, would be reported first, followed by codes for sepsis (eg, A41.9) and, when applicable, severe sepsis (R65.2-). Systemic Inflammatory Response Syndrome Due to Noninfectious Process When SIRS occurs due to a noninfectious process with no subsequent infection noted, report first the underlying condition, such as injury or trauma, followed by codes for the SIRS without acute organ dysfunction (R65.10) or with acute organ dysfunction (R65.11). When reporting code R65.11, report also a code for the specific organ dysfunction (eg, respiratory failure). When a noninfectious process leads to an infection and sepsis or severe sepsis, the codes reported are based on the focus of the encounter. For instance, when an infection and sepsis develop following a burn injury and the infectious conditions are chiefly responsible for the services provided at the encounter, list first the code for the systemic infection followed by codes for any localized infection, any associated severe sepsis with acute organ dysfunction, and the related burn injury. Coding Tip: Only one code from category R65, symptoms and signs specifically associated with systemic inflammation and infection, should be assigned. Assign only the appropriate code from subcategory R65.2, severe sepsis, when severe sepsis results from a noninfectious condition (ie, do not report a code from subcategory R65.1). The Table includes some of the ICD-10-CM codes that may be commonly reported in relation to sepsis in the newborn or pediatric patient. This list is not all inclusive, and it is recommended that the ICD-10-CM alphabetic index and tabular list be consulted for the most appropriate codes and sequencing instructions. Appendix B-5 Transitioning to 10: Coding for Sepsis (continued from page 233)
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