Home Health ICD-9/ICD-10 Alert

Hint: Don't make it primary.

When the clinician writes sepsis as primary, you code 995.91 - or do you? The answer could shock you.

When you look up "sepsis" in your coding manual's Alphabetic Index, it refers you to 995.91 (Systemic inflammatory response syndrome due to infectious process without organ dysfunction). But if you look in the Tabular List under 995.9x (Systemic inflammatory response syndrome [SIRS]), you find you must code the underlying condition before using 995.9x.
 
Many providers still don't realize ICD-9 guidelines no longer treat sepsis and septicemia as the same thing, notes James Kennedy with MA Health Solutions in Nashville, TN. "In the past, sepsis and septicemia were felt to be one and the same," but recent updates from the Centers for Medicare & Medicaid Services have clarified that they're separate. "Sepsis is the systemic, inflammatory response to a systemic infection, it is not the infection itself," says Kennedy.

If you look up "septicemia" in the Alphabetic Index, it refers you to 038.xx (Septicemia). And when you go to 038 in the Tabular List, you're instructed to "Use additional code for systemic inflammatory response syndrome [995.91-995.92]."

Assign either 995.91 (Systemic inflammatory response syndrome due to infectious process without organ dysfunction) or 995.92 (... with organ dysfunction) for sepsis. According to Coding Clinic for fourth quarter 2003, SIRS "implies that a localized infection has advanced to the point of a systemic infection."

Update: In its new ICD-9 coding guidance, which took effect April 1, CMS explains you can't ever list sepsis as a patient's primary diagnosis. If a patient has sepsis  on admission and it meets the definition of a primary diagnosis, then you should first assign the underlying systemic infection code.

Examples: If the patient has septicemia with sepsis (that is, with two or more manifestations of SIRS without organ dysfunction) you would code 038.xx (Septicemia) followed by 995.91. If the physician specifically indicates the infectious organism, such as E. coli (038.42), you should report a more specific, five-digit code.
 
Or for a patient with systemic candidiasis with sepsis, you would code 112.5 (Candidiasis, disseminated), followed by a code from the sepsis family, 995.9x.
 
Caution: Even if you think you know a patient has one of the sepsis-related diagnoses - perhaps based on lab values, symptoms or something the patient said - you must have physician documentation before you code for the diagnosis.

Often, physicians will list a diagnosis such as septicemia or bacteremia when the patient actually has sepsis. If you see documentation showing the patient has fever, high white blood cell count or organ failure such as heart failure, then you should go back to the physician and ask if the patient may have sepsis.

Most important: You must base your code assignments on physician documentation. Coders are not allowed to assign a code based on abnormal laboratory values without physician confirmation of the diagnosis, says Rita Rich, manager of coding compliance with Brentwood, TN-based LifePoint Hospitals.

Watch for: Physicians often will use terms such as "urosepsis," when they really just mean a urinary tract infection, says Kennedy. If so, you should assign 599.0 (Urinary tract infection, site not specified). If the physician does not clearly indicate whether the patient has a diagnosis of urosepsis or UTI, you must ask for clarification.

If the patient has urosepsis plus the signs of a systemic response to the infection, then the patient actually has sepsis. For urosepsis as a more widespread septicemia, report 038.9 (Unspecified septicemia) instead.

Add codes: If the patient's blood pressure is low and the patient has perfusion abnormalities, then the patient has septic shock, says Kennedy. The code for septic shock (785.52) should always follow the code for the underlying infection and the systemic inflammatory response syndrome code (995.92), CMS says. If the patient is experiencing specific organ dysfunction, assign codes for that also, CMS adds.

Tip: Postprocedural sepsis is a complication of care, CMS says. For postprocedural sepsis, you should use 998.59 (Other postoperative infection) followed by the sepsis code, CMS instructs.