Home Health ICD-9/ICD-10 Alert

Question: Our patient had a urinary tract infection and developed severe sepsis. The medical record doesn’t indicate a causative organism, but does mention septic shock. The patient is now home with oral antibiotics. Septic shock is resolved. How should I code for her?

Kansas subscriber

Answer: Code for this patient as follows:

• M1010: 038.9 (Unspecified septicemia);
                  995.92 (Severe sepsis); and
                  785.52 (Septic shock);
• M1020a: 038.9 (Unspecified septicemia);
• M1022b: 995.92 (Severe sepsis); and
• M1022c: 599.0 (Urinary tract infection, site not specified).

List the codes for your patient’s septic shock in M1010 — Inpatient diagnoses. This condition was resolved in the hospital before your patient returned home. To code for septic shock, you must list the code for the systemic infection first (038.9), followed by the code for severe sepsis (995.92), and finally the code for septic shock (785.52).

Coding guidelines for a patient with a principal diagnosis of severe sepsis require you to list a code for the systemic infection (or causal organism) first. When you don’t know the causal organism, as is the case in your patient’s situation, you’ll list 038.9.

Next, coding guidelines advise you to report the severe sepsis code, 995.92.

Finally, you should list a code for the localized infection. In this scenario, that’s your patient’s UTI, which you will report with 599.0.

In ICD-10 for this patient, you would list the following codes:

• M1010: A41.9 (Sepsis, unspecified organism)
                 R65.21 (Severe sepsis with septic shock) 
• M1020a: A41.9 (Sepsis, unspecified organism);
• M1022b: R65.20 (Severe sepsis without septic shock); and 
• M1022c: N39.0 (Urinary tract, site not specified).

In ICD-10, one code (R65.21) indicates both severe sepsis and septic shock. You’ll report R65.21 as an inpatient diagnosis in M1010, but because the septic shock has been resolved, you’ll code for severe sepsis alone in M1022. The sequencing instructions for reporting severe sepsis with a localized infection are the same in ICD-10 as they are in ICD-9.