Inpatient Facility Coding & Compliance Alert

Incorrectly coding sepsis in a hospital setting is easier than you might think, thanks to the range of terminology used to describe the condition. Take your first steps toward coding accuracy by understanding the difference between common terms – and how they differ from each other, despite how providers might document them.
Urosepsis is a catch-all term providers often use to describe both septicemia and a urinary tract infection. For accurate coding, determine which condition the patient has: sepsis or urinary tract infection. If you find documentation in the patient's record for both a diagnoses (urosepsis and septicemia), follow up with the physician to determine which diagnosis is more accurate.
ICD-10 prep: The term "urosepsis" does not exist in ICD-10. Guidelines for ICD-10 state:
(ii) Urosepsis  The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.
The ICD-10 Manual includes a note to "code to condition," which is why you won't find a generic/nonspecific diagnosis such as "urosepsis." If the provider documents urosepsis once ICD-10 goes into effect, you'll need to query to determine the appropriate code.
Septicemia is a systemic disease characterized by pathogenic microorganisms in the blood stream. The microorganisms can include bacteria, fungi, viruses, or other organisms that cause infection. Septicemia is an acute illness, not a chronic condition. Seeing that a patient has been diagnosed with septicemia doesn't automatically mean the patient has sepsis. Assign a septicemia diagnosis only when the physician documents the condition.
Systemic inflammatory response syndrome (SIRS) is defined as a clinical response to an insult, infection, or trauma that includes a systemic inflammation as well as elevated or reduced temperature, rapid heart rate, rapid respiration, and elevated white blood count.
You'll report a minimum of two diagnoses when coding SIRS: one for the underlying cause or infection (such as trauma) and another from subcategory 995.9x (Systemic inflammatory response syndrome). The fifth digit of the diagnosis code specifies the type of manifestation (such as with or without acute organ dysfunction).
Sepsis falls under the wider category of SIRS; it is SIRS due to an infection. Although providers might use "sepsis" and "septicemia" interchangeably, the terms are not synonymous from a coding perspective. Query the physician for clarification when appropriate.
Coding sepsis requires a minimum of two codes: a code for the systemic infection (such as 038.xx) and 995.91 (SIRS due to infectious process without organ dysfunction). If no causal organism is documented in the medical record, ask the physician or assign code 038.9 (Unspecified septicemia) for the secondary diagnosis.
Being able to report sepsis as a principal diagnosis depends on the provider's documentation. If sepsis is present on admission and meets the definition of principal diagnosis, sequence the systemic infection code (038.xx, 112.5, etc.) first, followed by 995.91. If sepsis develops during the hospital stay, list both the systemic infection code and 995.91 as secondary diagnoses.
A diagnosis of sepsis can be further categorized by severity and symptoms the patient experiences. Come back next month for a closer look at what the different types of sepsis actually involve and how you choose the correct codes.