ICD 10 Code for Sepsis Severe Sepsis and Septic shock with examples

In this article, let us learn about guidelines of ICD 10 code for sepsis – severe sepsis and septic shock with examples.

What is Sepsis?

Sepsis means potentially fatal condition caused when the body responses to the presence of infection or organisms in the blood.

• Choose the appropriate “A” code from the alphabetical index to indicate sepsis with type of infection or causal organism, if the doctor documents “Sepsis with type of infection or causal organism”.

For example:

1. Patient admitted hospital for Sepsis due to Escherichia Coli (E coli):

ICD 10 code for Sepsis due to E coli is A41.51

2. Patient presence for Sepsis due to Serratia:

ICD 10 code for sepsis due to Serratia is A41.53

• If the doctor documents “Sepsis” but the type of infection or causal organism is not specified, then will assign the A41.9 code, which indicates Sepsis, unspecified organism.

Sepsis with associated AOD (Acute Organ Dysfunction) or Severe Sepsis:

• If patient admitted for sepsis with associated acute organ dysfunction, then we have to assign or list the diagnoses code in the below format.

1. _
2. 2_
3. Report additional code to identify the specific AOD

Example:

1. A patient diagnoses sepsis with acute renal failure

ICD 10 code for sepsis with acute renal failure is A41.9, R65.20, N17.9

2. A patient diagnoses sepsis with acute respiratory failure

ICD 10 code for sepsis with acute respiratory failure is A41.9, R65.20, J96.00

• If sepsis documented is not corresponding or associated with acute organ dysfunction then do not assign the severe sepsis (R65.2_).

Note: If the provider documented is not clear as acute organ dysfunction is related to the sepsis or another condition, then it’s better to inquiry with provider before assigning the codes

Severe sepsis with septic shock:

Septic shock means severe sepsis associated with circulatory failure.

• Assign the code in the same above format(severe sepsis) as it represents the type of acute organ dysfunction. But here, we will report a code R65.21(which indicates severe sepsis with septic shock) instead of R65.20(severe sepsis).

For example:

A patient is admitted with severe sepsis, septic shock with acute renal failure

ICD 10 code for severe sepsis, septic shock with acute renal failure is A41.9, R65.21, N17.9

Localized Infection:

• If the patient admitted for sepsis or severe sepsis and localized infection(pneumonia or cellulitis), then we need to sequence the code in the following below order.

1. _
2. Localized infection CPT code
3. 2_
4. AOD

Example:

Patient presence with acute kidney failure due to severe sepsis from pseudomonas pneumonia

ICD 10 code is A41.9, J15.1, R65.20, N17.9

• If the patient admitted for localized infection and then develops a sepsis or severe sepsis after admission, then we need to sequence the code in following order.

1. Localized infection CPT code
2. _
3. 2_
4. AOD

Example:

Patient admitted with pseudomonas pneumonia and after admission patient develops severe sepsis with acute renal failure

ICD 10 code is J15.1, A41.9, R65.20, N17.9

Sepsis and severe sepsis associated with noninfectious process:

In this scenario we should the sequence the code in the following order

1. Non infections code(Burn or Traumatic)
2. _
3. 2_
4. AOD

Example:

Patient admitted with third degree burn of left lower leg and develops sepsis with septic shock.

ICD 10 code is T24.332A, A41.9, R65.21