Lecture Notes: Sepsis Coding Guidelines

Introduction

• Speaker: Hoang, the coding expert
• Target Audience: Those preparing for coding exams or seeking to advance in their coding careers
• Topic: Sepsis, Severe Sepsis, and Septic Shock Coding Guidelines
• Importance: Understanding sepsis coding is crucial for coding exams (CPC, COC, CCA) and professional practice

Key Terms and Definitions

Bacteremia

• Presence of bacteria in the bloodstream after trauma or infection

Sepsis

• The body's deadly response to an infection
• Considered urgent and life-threatening

Septicemia

• Systemic disease associated with microorganisms or toxins in the bloodstream

SIRS (Systemic Inflammatory Response Syndrome)

• A systemic response to infection or trauma
• Symptoms: fever, rapid heart rate (>90 bpm), tachycardia, elevated white blood cell count

Severe Sepsis

• Sepsis that progresses to organ dysfunction/failure (e.g., kidney or heart failure)

Septic Shock

• Circulatory failure related to severe sepsis
• Considered a type of acute organ dysfunction

Sepsis Spectrum and Symptoms

Sepsis

• Often results from infections in lungs, kidneys, UTI, or weakened immune system
• Symptoms: rapid heart rate (>90 bpm), rapid breathing (>20 breaths/min), fever, abnormal WBC count (>12,000 cells/cu mm), low pCO2

Severe Sepsis

• Defined by infection progressing to organ dysfunction/failure
• Requires documentation linking organ failure to sepsis

Septic Shock

• Most severe form, involving lungs, kidneys, and liver dysfunction
• Life-threatening, with 40% mortality rate
• Requires immediate treatment: IV fluids, vasopressors, antibiotics

Sepsis Coding Guidelines

General Guidelines

• Highly undercoded in hospital data, often due to poor documentation or coding errors
• Pay attention to coding guidelines to avoid revenue loss for hospitals

Common Coding Scenarios

1. Admission for Sepsis: Type of infection/causal organism unspecified
   • Code: A41.9 (Sepsis, unspecified organism)
2. Admission for Severe Sepsis
   • Minimum two codes required: A40-A41 for systemic infection, followed by R65.2 for severe sepsis
3. Septic Shock
   • Codes: A40-A41 for systemic infection, followed by R65.21 for severe sepsis with septic shock
   • Additional codes for acute organ dysfunction
4. Sepsis and Bacteremia
   • Code: R78.81 for bacteremia without organ dysfunction
5. Septicemia without a Specific Code
   • Use A41.9 for septicemia with no further detail
6. Sepsis in Special Cases (e.g., pregnancy, childbirth)
   • Follow guidelines from chapters 15 and 16 with additional codes like R65.2 for severe sepsis

Real-life Coding Exercises

Exercise 1: Anaerobic Gram-negative Sepsis

• Look under Sepsis > Anaerobic
• Code: A41.4 (Sepsis due to anaerobes)

Exercise 2: Sepsis due to MRSA

• Look under Sepsis > Staphylococcus, Methicillin-resistant (MRSA)
• Code: A41.02 (Sepsis due to MRSA)

Sequencing Guidelines

Severe Sepsis

1. Reason for Admission: Sepsis/Severe Sepsis with Local Infection (e.g., pneumonia)
   • Code systemic infection (A40-A41) first, then local infection
   • If severe sepsis, add R65.2
2. Local Infection on Admission, Sepsis Develops Later
   • Code local infection first, then sepsis or severe sepsis codes
3. Non-infectious Sepsis
   • Code non-infectious condition first, followed by resulting infection
   • If severe sepsis, add R65.2 and any organ dysfunction codes

Hospital Coding and POA Indicators

• For every diagnosis code, specify whether the condition was present on admission (POA)
• Non-POA can’t be principal diagnosis

Sepsis with Devices, Implants, and Procedures

1. Sepsis due to Device/Implant
   • Code device complication first, then specific infection
   • E.g.: T82.7XXA for device, followed by A41.9 for unspecified sepsis
2. Sepsis Post-Procedural
   • Code procedural complication first, e.g., T81.44XA, followed by specific infection code

Additional Case Studies and Coding Challenges