Outpatient Facility Coding Alert

Consider this assortment of new and revised rule changes.

The new coding year always brings an extensive amount of attention and scrutiny to the influx of new, revised, and deleted ICD-10-CM codes. And, while these changes are of great importance, the coding community often neglects one of the most fundamental components of the upcoming edition of the ICD-10-CM — the guidelines.

“While becoming familiar with the annual changes to specific ICD-10-CM codes is important, it is equally important to review the coding guidelines for additions, revisions and deletions,” says Amanda Corney, MBA, medical billing operations manager for Medical Resources Management in Rochester, New York.

In this issue, you’ll be covering each of the most fundamental changes on sepsis coding that are sure to have a profound impact on the way you address various diagnostic scenarios. From the sequencing of sepsis diagnoses to knowing when to use additional codes, this year’s new and revised set of ICD-10-CM sepsis guidelines is sure to affect your outpatient facility and ambulatory surgery center (ASC) coding.

Dive in for a closer look at all the most important sepsis changes to the 2019 ICD-10-CM guidelines.

Look Out for New Code Sequencing Instructions

The first guideline worth noting is a subtle one, but offers important additional instruction to the postprocedural sepsis guidelines in Section I.C.1.d (Sepsis, Severe Sepsis, and Septic Shock). Note the new guidelines in bold:

• “For such cases, the postprocedural infection infections following a procedure, a code such as T80.2, Infections following infusion, transfusion, and therapeutic injection from T81.40, to T81.43 Infection following a procedure, T88.0, Infection following immunization, or a code from O86.00 to O86.03, Infection of obstetric surgical wound, that identifies the site of the infection should be coded first, followed by the if known. Assign an additional code for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04). Use an additional code to identify the specific infection infectious agent. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.” In addition to some semantic changes, you’ll want to take specific note of the instructions on the sequencing of codes. First, you will select one of the appropriate codes listed above to report the underlying postprocedural infection. Next, you will either report T81.44- (Sepsis following a procedure) or O86.04 (Sepsis following an obstetrical procedure) depending on the patient’s surgical status. Next, you will report a third code to identify the infectious agent. Finally, you will report a code from R65.2- (Severe sepsis) if the patient has documented severe sepsis.

Consider This Entirely New Postprocedural Infection Policy

Within the same set of guidelines, the ICD-10-CM offers one entirely new rule regarding postprocedural infections following infusion, transfusion, therapeutic injection, or immunization:

• “For infections following infusion, transfusion, therapeutic injection, or immunization, a code from subcategory T80.2, Infections following infusion, transfusion, and therapeutic injection, or code T88.0-, Infection following immunization, should be coded first, followed by the code for the specific infection. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned, with the additional codes(s) for any acute organ dysfunction.”

One important point to note with this guideline is that there is no instruction that you should report postprocedural sepsis codes T81.44 or O86.04 as secondary diagnoses, if applicable. Instead, you should only report R65.2 if the physician documents severe sepsis.

Coder’s note: Most of the codes referenced are new as of 2019, so be sure to brush up on all the guidelines that are affected by the plethora of new diagnosis codes.

Note More Sequencing Guidelines for Sepsis, Septic Shock Diagnoses

The last guideline to note under Section I.C.1.d pertains to a revision to the postprocedural infection and postprocedural septic shock coding guidelines:

• In cases where a postprocedural infection has occurred and has resulted in severe sepsis the code for the precipitating complication such as code T81.4, Infection following a procedure, or O86.0, Infection of obstetrical surgical wound should be coded first followed by code R65.20, Severe sepsis without septic shock. A code for the systemic infection should also be assigned.​ “If a postprocedural infection has resulted in postprocedural septic shock, the code for the precipitating complication such as code T81.4, Infection following a procedure, or O86.0, Infection of obstetrical surgical wound should be coded first assign the codes indicated above for sepsis due to a postprocedural infection, followed by code T81.12-, Postprocedural septic shock. A Do not assign code for the systemic infection R65.21, Severe sepsis with septic shock. Additional code(s) should also be assigned for any acute organ dysfunction.”

As you can see, ICD-10-CM almost completely overhauls its prior guidelines on postprocedural infection and septic shock coding. For a patient experiencing postprocedural septic shock following an infection, ICD-10-CM first instructs you to follow by the guidelines listed above. Unfortunately, ICD-10-CM does not elaborate any further, but it’s to be assumed that you will report each diagnosis in the following order:

• The postprocedural infection code (T81.40-T81.43, T88.0, O86.00-O86.03)
• Sepsis following a procedure (T81.44 or O86.04)
• Code to identify the infectious agent
• T81.12-.

Refresher: Abiding by these new sepsis guidelines requires a firm knowledge of what constitutes a sepsis versus septic shock diagnosis. “The ICD-10-CM official guidelines on sepsis explain it best: ‘Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction,’ whereas sepsis is a systemic response to infection,” relays Stephan Tong, CPB, CPC, COC, revenue cycle management freelancer at stongrcm.com. “Septic shock occurs when septic infection of the bloodstream has become so severe that the patient will fall into a very dangerous hypotensive state,” explains Tong.

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