TIPS for Sepsis Coding

Additional AHA Coding Clinic Clarification

Viral Sepsis (Coding Clinic, Third Quarter 2016: Page 8)

Question:

How would viral sepsis be coded in ICD-10-CM? The type of viral infection is unspecified. In ICD-9-CM, “Viral” was a sub term under septicemia, but it is not present as a sub term under sepsis in ICD-10-CM. By selecting “sepsis with specified organism NEC” code A41.89 is referenced. However, in ICD-10-CM, categories A30-A49 encompass “other bacterial diseases.” Would it be appropriate to assign a bacterial code for a viral condition?

Answer:

Assign codes A41.89, Other specified sepsis, and B97.89, Other viral agents as the cause of diseases classified elsewhere. Although codes in categories A30-A49 classify bacterial illnesses, there is no specific code for viral sepsis. “Sepsis, specified organism NEC” is indexed to code A41.89. Code A41.89 is the best available option to capture the concept of sepsis, since ICD-10-CM does not have a specific code for viral sepsis, along with code B97.89 to provide an additional level of specificity when the virus is not specified.

 

Sepsis due to Aspiration Pneumonia (Coding Clinic for ICD-10-CM/PCS, Second Quarter 2020: Page 28)

Question:

When the provider documents “sepsis due to aspiration pneumonia,” is a code for the sepsis, or the aspiration pneumonia assigned as the principal diagnosis?

Answer:

Assign code A41.9, Sepsis, unspecified organism, as the principal diagnosis. Codes J18.9, Pneumonia, unspecified organism, and J69.0, Pneumonitis due to inhalation of food and vomit, should be assigned as additional diagnoses. Sepsis indicates infection and the body’s response to it. Aspiration pneumonia may be just from the direct effect of inhaled material, such as a chemical effect, or it may involve infection; however, for sepsis to result, it would need to involve an infectious pneumonia. Therefore, codes J18.9 and J69.0 are both needed to show the presence of a localized infection (pneumonia and unspecified organism) as well as pneumonia due to aspiration. When sepsis and aspiration pneumonia are related (i.e., sepsis due to aspiration pneumonia or sepsis related to aspiration pneumonia) and present on admission, sepsis should be sequenced as the principal diagnosis.

 

Tips and Reminders:

• Always read the full ICD-10-CM chapter-specific coding guidelines for sepsis in chapters 1 and 15 (if applicable).
• Always read any coding instructions under the diagnosis codes for “code-first” and “use additional” code notes.
• Review any pertinent AHA Coding Clinic(s) that pertain to sepsis.

 

 

References:

ICD-10-CM Chapters 1 and 15 2023 ICD-10-CM Documentation Guidelines

Coding Clinic for ICD-10-CM/PCS, First Quarter 2018: Page 16

Coding Clinic, Third Quarter 2016: Page 8