Correct coding of sepsis or septicemia continues to be an area of concern for coders and a target of RAC. Whenever there is a question about sepsis, or any diagnosis, we are instructed to go back to the Official Guidelines for Coding and Reporting along with further guidance from Coding Clinic.
First, does the patient have sepsis? Having a positive culture does not automatically indicate septicemia or sepsis, just as having a negative culture does not preclude the diagnosis of sepsis or septicemia. The physician is the only one who can make the determination that the patient has septicemia or sepsis taking into account all the clinical factors the patient presents with.
While physicians sometimes use the terms septicemia and sepsis interchangeably, and sometimes even bacteremia, they are not considered the same.
- Bacteremia is defined as the presence of bacteria in the blood.
- Septicemia has been defined as systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi or other organisms.
- The systemic inflammatory response syndrome (SIRS) is the systemic response to infection or trauma, with symptoms including fever, tachycardia, tachypnea, and leukocytosis.
- Sepsis is defined as SIRS due to infection.
“If sepsis or severe sepsis is present on admission, and meets the definition of principal diagnosis, the systemic infection code (e.g., 038.xx, 112.5, etc) should be assigned as the principal diagnosis.”
“When sepsis or severe sepsis develops during the encounter (it was not present on admission), the systemic infection code and code 995.91 or 995.92 should be assigned as secondary diagnoses.”
“If the reason for admission is both sepsis, severe sepsis, or SIRS and a localized infection, such as pneumonia or cellulitis, a code for the systemic infection (038.xx, 112.5, etc.) should be assigned first, then code 995.91 or 995.92, followed by the code for the localized infection.
Physician Documentation and Queries:
The physician must provide complete documentation in the medical record to support the diagnosis of sepsis, including clinical indicators, diagnostic workup, and treatment plan.
- If the documentation is unclear whether the sepsis was present on admission, the physician must be queried.
- If there does not appear to be documentation supporting the diagnosis of sepsis, the physician must be queried.
- If there appears to be documentation supporting a diagnosis of sepsis, but the diagnosis has not been documented by the physician, query the physician to determine if the clinical indicators are significant and if so, what is the diagnosis.
- Coding Clinic Fourth Quarter 2003, Pages 79 to 81
- Coding Clinic Second Quarter 2002, Pages 36 to 39