Sepsis is the body’s extreme response to an infection. It occurs when an infection you already have in your skin, lungs, urinary tract, or somewhere else triggers a chain reaction throughout your body. Anyone can get an infection, and almost any infection can lead to sepsis including bacterial, viral or fungal infections.
Globally, an estimated 20 million to 30 million cases of sepsis occur each year. Hospitalizations for sepsis have more than doubled over the past 10 years, and the incidence of sepsis developing after surgery tripled from 1997 to 2006. Mortality from sepsis is estimated to be greater than mortality from AIDS and breast cancer combined.
Common signs and symptoms of sepsis:
Coding a patient’s record with sepsis can prove challenging for medical coders. For example, the ICD-10 Official Coding Guidelines tell us signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. If the patient is admitted with a localized infection and sepsis, the code for the systemic infection should be assigned first, followed by a code for the localized infection. If the patient is admitted with a localized infection, and develops sepsis after admission, a code for the localized infection is assigned first, followed by a code for the sepsis.
A systemic infection can occur as a complication of a procedure or due to a device, implant or graft. This includes systemic infections due to wound infections, infusions, transfusions, therapeutic injections, implanted devices, and transplants.
When sepsis is complicating pregnancy, childbirth, or the puerperium, the obstetrical code is sequenced first, followed by a code for the specific infection. When a newborn is diagnosed with sepsis, a code from category P36 Bacterial sepsis of the newborn is assigned.
Both the coding guidelines for sepsis as well as ambiguous provider documentation often mean coders require an extended length of time to review a record – only to place it on hold for a physician query. It is up to the physician’s clinical judgement to decide whether the patient has sepsis. The coder cannot assume the patient has sepsis based on criteria being met – they must rely on the physician’s documentation. Coders should emphasize to physicians the importance of capturing patient severity which will be reflected in accurate coding and correct facility reimbursement.
From a patient’s perspective, there are ways to help prevent sepsis.
Knowing the signs and symptoms of sepsis is a medical coder’s first step towards accurately coding what can be a life-threatening illness. Coders should take the time to thoroughly review and learn from these records rather than be overwhelmed by them.
It is also important to review how to apply sequencing guidelines and to query the physician for any ambiguous or conflicting information present in the patient’s record.
Cynthia Alder-Smith RHIT, CCS