Health Information Management

Tip: Take time for a sepsis refresher

CDI Strategies, October 29, 2009

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Sepsis. Severe sepsis. SIRS. Septicemia. Unfortunately, this isn’t a case of “tomato, tomahto.” Coders and physicians need to know how to use these terms accurately, or inaccurate billing and coding is a real possibility.
It is interesting to note that “septicemia” does not exist in the ICD-10 codes. When you reference it in ICD-10, it leads you to R78.81 (bacteremia NOS). Sepsis codes have become more defined in ICD-10 and documentation will be critical. For example, the term sepsis alone takes you to code A41.9 (other sepsis). However, depending on the modifying term, the code may change as in this example: When the physician documents the causative organism, such as group B strep, the code changes to A40.1. Also, when the physician documents severe sepsis in ICD-10, it takes you to code R65.20 (severe sepsis without septic shock).
As a refresher, sepsis refers to the “systemic inflammatory response to the infection” and is manifested by three or more of the following SIRS conditions in a patient:
  • Body temperature > 38.3°C (101°F) or < 36°C (96.8°F)
  • Pulse > 90/min.
  • Respirations > 20/min
  • White blood cell (WBC) count > 12,000 or < 4,000
  • Altered mental status
  • Significant edema or positive fluid balance
  • Hyperglycemia (without diabetes)
Severe sepsis refers to sepsis associated with organ dysfunction or failure,
hypoperfusion (i.e., decreased blood flow through an organ), or hypotension
(i.e., abnormally low blood pressure).
Editor’s note: Jennifer Avery, CCS, CPC, CPC-H CPC-I, senior regulatory specialist at HCPro, Inc., offers additional information in the Revenue Cycle Institute White Paper “Sepsis and Septicemia: Clear Up Coding and Documentation Confusion” available free following registration.

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