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July 12, 2004

Coding for SIRS, Sepsis, and Septicemia
Vol. 16 No. 14 p. 31

HIM professionals have been adapting to the coding changes for systemic inflammatory response syndrome (SIRS), sepsis, and septicemia since October 1, 2003. AHA Coding Clinic for ICD-9-CM has provided some direction regarding the coding and sequencing of these diagnoses in fourth quarter 2003, pages 79-81 and 113-115. However, many questions are still being raised regarding the sequencing of sepsis and the physician documentation requirements.

Definitions and Sequencing
Refer to Table 1 for a review of the definition of the diagnoses and ICD-9-CM code assignments.

According to the American College of Chest Physicians and the Society of Critical Care Medicine, the clinical manifestations of SIRS include the following:

• Fever (temperature >100.4°F) or hypothermia (temperature <96.8°F)

• Leukocytosis (white blood (cell) count) [WBC] >12,000 cells per cubic millimeter) or leukopenia (WBC <4,000 cells per cubic millimeter) or >10% bands

• Tachycardia (heart rate >90 beats per minute)

• Hyperventilation (respiratory rate >20 breaths per minute or PaCO2 <32 milligrams of mercury)

For coding purposes, a code from subcategory 995.9 will rarely be sequenced as the principal diagnosis. The underlying cause of the SIRS should be sequenced first, with the default code being a code from category 038. According to AHA Coding Clinic for ICD-9-CM, “If the terms sepsis, severe sepsis, or SIRS are used with an underlying infection other than septicemia, such as pneumonia, cellulitis or a nonspecified urinary tract infection, code 038.9 should be assigned first, then code 995.91, followed by the code for the initial infection” (AHA Coding Clinic for ICD-9-CM, 2003, fourth quarter, page 80). The reasoning is that the systemic infection should be sequenced before the localized infection.

Due to the new sepsis coding guidelines, several questions have been asked regarding the sequencing of sepsis with other conditions. The following is suggested advice to follow when coding these types of records:

• Sepsis due to chronic cholecystitis and cholecystectomy performed
AHA Coding Clinic for ICD-9-CM states that chapter specific guidelines take precedence over general coding guidelines (AHA Coding Clinic for ICD-9-CM, 2003, first quarter, page 15). Therefore, since the sepsis guidelines are chapter-specific guidelines, the sepsis should be sequenced as the principal diagnosis when a patient is admitted with sepsis due to chronic cholecystitis.

• Admitted with sepsis, pneumonia, and respiratory failure
According to AHA Coding Clinic for ICD-9-CM, a patient admitted with pneumonia and sepsis goes to sepsis as the principal diagnosis (2003, fourth quarter, pages 79-81). A patient admitted with pneumonia and respiratory failure goes to respiratory failure as the principal diagnosis (2003, second quarter, pages 21-22). When a patient is admitted with respiratory failure due to or associated with an acute nonrespiratory condition (sepsis), then the acute nonrespiratory condition is sequenced as the principal diagnosis (1991, second quarter, pages 3-5). Since respiratory failure is an organ dysfunction of SIRS/sepsis, it should be listed as a secondary diagnosis. Therefore, if a patient is admitted with sepsis, pneumonia, and respiratory failure, then the sepsis will more than likely be sequenced as the principal diagnosis as it is the acute condition causing the respiratory failure. However, if the documentation specifically supports that the respiratory failure was caused by another respiratory condition and not caused by the sepsis, then it may be appropriate to sequence the respiratory failure as the principal diagnosis.

• Admitted with pneumonia and sepsis develops after admission
If the sepsis developed after admission, then it would not be appropriate to sequence the sepsis as the principal diagnosis. Therefore, in this case, it would be appropriate to sequence the pneumonia as the principal diagnosis.

• Septic arthritis with sepsis
Septic arthritis is an infection contained to the affected area. It is not a truly septic condition. A patient with septic arthritis may not have sepsis. However, it is possible to also have septic arthritis with sepsis. Therefore, if the patient presents with both septic arthritis and sepsis, then it would be appropriate to sequence the sepsis as the principal diagnosis.

• Line sepsis
The coding rule for sepsis due to a device does not change. The infection due to a device (996.62) will continue to be the principal diagnosis in this case. Code 038.x and 995.91 will be coded as secondary diagnoses.

Documentation Requirements
From a coding perspective, sepsis is no longer synonymous with septicemia. However, physicians may continue to use the terms interchangeably. Therefore, it may be necessary to query the physician for clarification depending on the documented terms and the patient’s condition.

The physician must document either sepsis or SIRS before a code from subcategory 995.9 can be assigned as an additional diagnosis. If only septicemia is documented, it may be appropriate to query the physician for clarification if the patient exhibits some of the manifestations of SIRS/sepsis.

However, if the physician documents sepsis but the patient does not present with manifestations of SIRS, then it may be appropriate to confirm with the physician if the patient really does have sepsis.

The coding guidelines for urosepsis remain the same. If only urosepsis was documented, then code 599.0 would be assigned. However, it would be appropriate to query the physician for clarification to determine whether urosepsis means the patient has septicemia or sepsis with a urinary tract source or an infection contained within the urinary tract.

Coding and sequencing for SIRS, sepsis, and septicemia are dependent upon the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, and Vicki Sippel, RHIA, of 3M Health Information Systems (800-367-2447), a leading supplier of coding and classification systems to nearly 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information.

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