Coding guideline 1.C.1.d.1.b. Severe Sepsis
The coding of severe sepsis requires a minimum of two codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. Additional code(s) for the associated organ dysfunction are also required.
Patient taken to emergency department after being found semi-conscious with markedly abnormal vital signs, a fever of over 39 degrees C, a heart rate of 100, and a respiratory rate of 22/min. On admission to the ICU the physician documented her condition as severe sepsis with acute respiratory failure. The final diagnosis, provided by the physician, was gram-negative sepsis with acute respiratory failure.
A41.50, Sepsis (generalized), gram-negative (organism). Review Tabular for complete code assignment.
R65.20, Sepsis, with organ dysfunction (acute) (multiple)
J96.00, Failure, failed, respiration, respiratory, acute
Rationale: Under the R65.2 subcategory, there is a “code first underlying infection” note; therefore, A41.50 should be listed as the principal diagnosis followed by R65.20 as a secondary diagnosis. Coding Guidelines C.1.d.1.b provides sequencing guidance for severe sepsis: “the coding of severe sepsis requires a minimum of two codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis.” Code J96.00 is used to identify the acute respiratory failure.
CODING TIP: Remembering which infection code to use will be key to proper coding in ICD-10. Codes in section “A” will be coded as the first listed diagnosis unless a specific coding tip instructs otherwise… remember “A” is for Alpha. This does not necessarily mean it will be the primary diagnosis in M1021a, it will just be the first in the sequence of codes for the infection. Codes in section “B90-97” are used as a secondary diagnosis and are used in “diseases classified elsewhere.”