April 16, 2019

Coding Sepsis:  Knowing the Signs and Symptoms

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:

  • Altered mental status, drop in urine output, and decreased capillary refill of nail beds or skin
  • Fever (temperature greater than 100.4 degrees) or hypothermia (temperature less than 96.8 degrees)
  • Leukocytosis (white blood cell count greater than 12,000) or leukopenia (white blood cell count less than 4,000 or greater than 10% bands)
  • Hypotension (systolic blood pressure < 90 mm Hg or fallen by > 40 from baseline, mean arterial blood pressure < 70 mm Hg)
  • Lactate >1 mmol/L.
  • Tachycardia (greater than 90 beats per minute)
  • Tachypnea (respiratory rate greater than 20 breaths per minute or a pCO2 of less than 32 mmHg)

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.

  • Get vaccinated. According to a recent CDC study, 35% of sepsis cases stemmed from pneumonia. Annual flu shots can also prevent respiratory infections that often turn septic.
  • Treat urinary tract infections promptly. A quarter of sepsis cases resulted from urinary tract infections. It is important to see a healthcare provider if you have warning signs of those infections including a painful burning feeling when urinating and a strong urge to ‘go’ often.
  • Clean skin wounds properly. About one in 10 sepsis cases follows a skin infection. It is essential to care for wounds and scrapes properly – washing with soap and water, cleaning out any dirt and debris, and covering wounds. 
  • Avoid infections in hospitals. Insist that everyone who comes into your hospital room, including doctors and nurses, wash their hands before they touch you.

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

Auditor/Coding Educator