2023 ICD 10 CM coding guidelines for sepsis
TLDRThe transcript discusses the 2023 ICD-10 CM coding guidelines for sepsis, including coding for sepsis with localized infection, severe sepsis, and septic shock. It highlights the new addition of hemolytic uremic syndrome associated with sepsis and emphasizes the importance of accurate coding based on clinical documentation. The guidelines clarify when to assign specific codes for sepsis, severe sepsis, and related complications, and provide examples to illustrate the correct coding sequence.
Takeaways
- 📌 The 2023 ICD-10 CM coding guidelines introduce new coding rules for sepsis, including hemolytic uremic syndrome associated with sepsis, effective from October 2022.
- 🔍 For sepsis coding, assign the appropriate code from the underlying systemic infection. If the infection type or causal organism is unspecified, use code A41.9 (sepsis, unspecified organism).
- 🚫 Negative or inconclusive blood cultures do not preclude a sepsis diagnosis. There is no specific ICD-10 code for negative or inconclusive blood cultures.
- 🦠 Neurosepsis is a non-specific term and should not be used synonymously with sepsis. It lacks a default code in the alphabetical index and should prompt a query if used by a provider.
- 💡 Severe sepsis should be coded with at least two codes: the underlying systemic infection (e.g., A41.9) and R65.20 (severe sepsis without septic shock), plus any associated organ dysfunction codes.
- 🩺 For sepsis with acute organ dysfunction not clearly associated with sepsis, do not assign the severe sepsis code (R65.20). Query the provider for clarification if the documentation is unclear.
- 🌟 Septic shock is a type of acute organ dysfunction related to the circulatory system and should be coded with the systemic infection code first, followed by R65.21 (severe sepsis with septic shock).
- 👶 Newborn sepsis is coded under category P36, and if the causal organism is identified, additional codes from category B96 may be required. The default assumption for sepsis in neonates is congenital unless documented as community-acquired.
- 🤰 Sepsis complicating abortion, pregnancy, childbirth, or the puerperium is coded with chapter 15 codes taking priority as the principal diagnosis, followed by sepsis codes and any severe sepsis or associated organ dysfunction codes.
- 🕑 The timing of sepsis development during an encounter affects coding. If severe sepsis develops during the encounter and was not present on admission, the underlying systemic infection should be the principal diagnosis.
- 📈 The transcript provides detailed examples of coding scenarios, emphasizing the importance of following the specific ICD-10 CM guidelines for sepsis and its related conditions.
Q & A
What are the key components of the 2023 coding guidelines for ICD-10 CM regarding sepsis?
-The 2023 guidelines for ICD-10 CM coding of sepsis include coding for sepsis, severe sepsis, septic shock sequences, sepsis with localized infection, post-procedural sepsis, sepsis associated with non-infectious processes, and complications of abortion, pregnancy, childbirth, and the newborn. A new addition is hemolytic uremic syndrome associated with sepsis.
How is sepsis coded when the blood cultures are negative or inconclusive?
-Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis if there is clinical evidence of the condition. However, there is no specific ICD-10 CM code for negative or inconclusive blood cultures. The provider should be queried in such cases.
What is the correct ICD-10 CM code for sepsis due to an unspecified organism?
-For sepsis due to an unspecified organism, the appropriate ICD-10 CM code is A41.9.
What are the coding requirements for severe sepsis with acute organ dysfunction?
-For severe sepsis with acute organ dysfunction, two codes must be given: A41.9 for sepsis unspecified organism, and R65.20 for severe sepsis without septic shock, along with any associated organ dysfunction codes.
How is neurosepsis differentiated from sepsis in ICD-10 CM coding?
-Neurosepsis is a non-specific term and is not synonymous with sepsis. It has no default code in the alphabetical index of ICD-10 CM. If a provider uses this term, they must be queried for clarification.
What is the correct sequence for coding septic shock in relation to systemic infection?
-Septic shock cannot be assigned as the principal diagnosis. The code for the systemic infection should be sequenced first, followed by R65.21 for severe sepsis with septic shock or T81.12 series for post-procedural septic shock.
How should sepsis and severe sepsis be coded when they are associated with a localized infection?
-When sepsis or severe sepsis and a localized infection are both reasons for admission, the code for the underlying systemic infection should be assigned first, followed by the code for the localized infection and then the code for severe sepsis if present.
What is the process for coding sepsis due to post-procedural infection?
-Documentation of a causal relationship must be present. The code for the infection following the procedure (T81.40 to T81.43 for non-obstetric, O86.00 to O86.04 for obstetric) should be coded first, followed by additional codes for sepsis and any severe sepsis or associated organ dysfunction.
How are cases of sepsis complicating pregnancy, childbirth, and the puerperium coded?
-Chapter 15 codes take priority and should be given as the principal diagnosis (PDX). The specific infection code should be assigned as an additional diagnosis, followed by any severe sepsis code (R65.2) and associated organ dysfunction codes.
What is the appropriate ICD-10 CM code for a patient with a third-degree burn who develops sepsis with septic shock?
-The appropriate ICD-10 CM code for a patient with a third-degree burn who develops sepsis with septic shock is T24.332A for the third-degree burn, followed by A41.9 for sepsis, and R65.21 for severe sepsis with septic shock.
How is newborn sepsis coded in ICD-10 CM?
-Newborn sepsis is coded using the P36 category, which includes bacterial sepsis of the newborn. If the causal organism is documented, an additional code from category B95 may be required, unless the P36 code already includes the organism.
What is the new guideline introduced for hemolytic uremic syndrome associated with sepsis?
-For hemolytic uremic syndrome associated with sepsis, the principal diagnosis should be D59.31 infection associated hemolytic uremic syndrome, followed by codes for the underlying systemic infection and any other conditions such as severe sepsis.
Outlines
📚 Introduction to 2023 ICD-10 CM Coding Guidelines for Sepsis
This paragraph introduces the topic of 2023 ICD-10 CM coding guidelines, focusing on sepsis and severe sepsis. It outlines the various aspects of coding for sepsis, including guidelines for sepsis with localized infection, post-procedural sepsis, and sepsis associated with non-infectious processes. The new addition of hemolytic uremic syndrome associated with sepsis is also highlighted. The paragraph emphasizes the importance of assigning the correct codes based on the underlying infection and the presence of severe sepsis or septic shock, with specific mention of the code A41.9 for sepsis unspecified organism.
🩺 Coding for Acute Organ Dysfunction and Neurosepsis
This section delves into the coding guidelines for acute organ dysfunction related to sepsis. It clarifies that acute organ dysfunction not clearly associated with sepsis should not be coded with severe sepsis codes. The term 'neurosepsis' is discussed as a non-specific term without a default code and should not be used synonymously with sepsis. The paragraph also provides an example of coding for a patient with sepsis and acute respiratory failure due to COPD, emphasizing that the acute organ failure must be related to sepsis to assign the severe sepsis code.
💉 Sepsis and Severe Sepsis Coding Scenarios
This paragraph discusses various scenarios involving sepsis and severe sepsis coding. It explains the coding process for sepsis with localized infection, post-procedural sepsis, and sepsis due to non-infectious processes like trauma. The paragraph provides detailed examples, including coding for a patient with pseudomonas pneumonia leading to severe sepsis and acute renal failure. It also covers the coding of septic shock, emphasizing that septic shock codes cannot be assigned as the principal diagnosis and must be sequenced by systemic infection codes first.
🌡️ Infections Following Medical Procedures and Immunization
This section addresses the coding of infections following medical procedures and immunization. It outlines the coding priorities for infections following infusion, transfusion, therapeutic injection, and immunization. The paragraph provides specific examples, including a case of MRSA cellulitis following surgical removal of an appliance. It also discusses the coding of post-procedural septic shock and emphasizes the use of additional codes to identify the infectious agent and any acute organ dysfunction.
🤰 Sepsis Complicating Pregnancy, Childbirth, and the Newborn
This paragraph focuses on the coding of sepsis complicating pregnancy, childbirth, and the newborn. It provides guidelines for assigning chapter 15 codes for maternal infections and specifies the coding for perforated uterus and purpural sepsis. The paragraph also discusses the coding of newborn sepsis, including the use of category P36 for bacterial sepsis in newborns and the importance of identifying the causal organism. An example is given for a full-term infant developing sepsis due to E. coli, highlighting the assignment of codes for sepsis, severe sepsis, and the causal organism.
🩸 Hemolytic Uremic Syndrome and Sepsis: New Guidelines
The final paragraph introduces new guidelines for coding hemolytic uremic syndrome associated with sepsis, effective from October 2022. It explains that when hemolytic uremic syndrome is associated with sepsis, the primary code assigned should be D59.31, infection associated hemolytic uremic syndrome, followed by codes for the underlying systemic infection and other conditions such as severe sepsis. The paragraph concludes with a prompt for further videos on medical coding and CPC training.
Mindmap
Keywords
💡ICD-10 CM coding
💡Sepsis
💡Severe Sepsis
💡Septic Shock
💡Negative or Inconclusive Blood Cultures
💡Neurosepsis
💡Acute Organ Dysfunction
💡Post-Procedural Infection
💡Non-Infectious Processes
💡Hemolytic Uremic Syndrome
💡Newborn Sepsis
Highlights
Discussion of 2023 coding guidelines for ICD-10 CM coding, focusing on sepsis.
New addition to guidelines: hemolytic uremic syndrome associated with sepsis, effective from October 2022.
Sepsis coding depends on the underlying systemic infection; if unspecified, use code A41.9.
Severe sepsis coding requires documentation of associated acute organ dysfunction, using code R65.20.
Negative or inconclusive blood cultures do not preclude a sepsis diagnosis if there is clinical evidence.
Neurosepsis is a non-specific term without a default code and should not be used synonymously with sepsis.
For sepsis with organ dysfunction not clearly associated with sepsis, do not assign code R65.20.
Severe sepsis coding requires at least two codes: A41.9 for sepsis and R65.20 for severe sepsis without septic shock.
Septic shock coding involves sequencing the systemic infection code first, followed by R65.21 for severe sepsis with septic shock.
Sepsis due to post-procedural infection requires documentation of the causal relationship between the infection and the procedure.
Infections following infusion, transfusion, therapeutic injection, or immunization are coded with T80.2 or T88.0 series.
Sepsis or severe sepsis associated with non-infectious processes like trauma should list the non-infectious condition as the primary diagnosis if it meets the definition of PDX.
Sepsis complicating abortion, pregnancy, childbirth, or the puerperium is coded with chapter 15 codes taking priority.
Newborn sepsis is coded with category P36, with additional codes for the causal organism if documented.
Hemolytic uremic syndrome associated with sepsis is coded with B59.31 as the primary diagnosis.
Transcripts
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