As noted in the Tabular List, the code for septic shock CANNOT be assigned as a principal diagnosis. After the kidney function improved, the patient underwent surgery for care of the left heel. Without the diagnosis of sepsis falling into one of those chapters, coders should follow the ICD-10-CM Official Guidelines for Coding and Reporting of sepsis, severe sepsis and septic shock. For such cases, the post procedural infection code, such as T80.2, Infections following infusion, transfusion, and therapeutic injection, T81.4, Infection following a procedure, T88.0, Infection following immunization, or O86.0, Infection of obstetric surgical wound, should be coded first, followed by the code for the specific infection. acute kidney failure, list Sepsis, unspecified organism (A41.9) as the principal diagnosis, Severe sepsis (R65.2-), Acute kidney failure (N17.-), and Urinary tract infection, site not specified (N39.0) are listed as contributing diagnoses. (Septic shock indicates severe sepsis is also present.) Gavins, in Vascular Responses to Pathogens, 2016. Sorry, your blog cannot share posts by email. Severe sepsis may occur with or without sepsis-induced hypotension (e.g., with fever, encephalopathy and renal failure but a normal blood pressure). A: Likely, in the case you describe, the patient had sepsis that was due to a catheter-associated UTI (CAUTI). Multiple Organ Dysfunction Syndrome (MODS) = Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention. The aim of the study was to assess the diagnostic usefulness of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in sepsis, severe sepsis and septic shock against interleukin-6 (IL-6), C-reactive protein (CRP) and procalcitonin (PCT). Sensitivities and specificities of clinical signs and biochemical tests in sepsis diagnosis are not satisfactory. If severe sepsis is clearly present on admission and meets the definition of principal diagnosis, the systemic infection code (038.xx, 112.5, etc.) Sepsis is usually considered severe when the patient exhibits at least one of the following signs and symptoms (which may indicate an organ may be failing): Refractory (Septic) Shock/SIRS Shock = A subset of severe sepsis (SIRS) and defined as sepsis (SIRS) induced hypotension despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status. He has special interest in ethics, patient safety, disease management, and management and leadership of people. Retrospective Reviews: The last line of defense? Additional codes for any associated acute organ dysfunction are also required. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism.” When severe sepsis develops during an admission (it was not present on admission) the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as secondary diagnoses. There is also an Excludes1 for “severe sepsis” which is found in R65.2-. Coding of Septic Shock The misinterpretation relates to the sequencing of codes. SIRS (Systemic Inflammatory Response Syndrome) = The systemic inflammatory response to a wide variety of severe clinical insults, manifested by two or more of the following conditions: Sepsis = The systemic inflammatory response to infection and is defined as the presence of SIRS (Systemic Inflammatory Response Syndrome) in addition to a documented or presumed infection. A code from subcategory R65.2 can never be assigned as a principal diagnosis. He is the CEO of ionHealthcare® LLC, a company that specializes in healthcare consulting, risk adjustment coding, management & support services. I know the guidelines for coding sepsis, but I have to question them in two scenarios for which I was told to use sepsis as my principal diagnosis. For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Post-procedural septic shock. Tachycardia, tachypnea, and hyperthermia are classic features [ 7][ 10]. In some cases, bloodstream infection cannot be detected, and doctors use other information such as body temperature and mental status to diagnose sepsis. The principal elements of the most recent guidelines are summarized in this practice point. For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. 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