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Tips for Coding Sepsis in ICD-10
By Jon Elion, MD, FACC

The coding requirements for sepsis have been refined slightly for ICD-10, but common sense continues to be a useful guiding principle for physician documentation.

• Does the patient look sick, toxic, or septic? If not, simply tallying up a Systemic Inflammatory Response Syndrome (SIRS) score cannot substitute for clinical judgement. A patient with a urinary tract infection with a high white blood cell count and a fever over 101°F technically meets the criteria for SIRS, but it may be a bit of a stretch to call this clinical sepsis.
• The terms "septicemia," "bacteremia," and "sepsis" are often used interchangeably by physicians, even though these are not necessarily all describing the same clinical condition. In ICD-9, there were codes whose description included the word "septicemia," but that word does not appear in the corresponding ICD-10 codes. Physicians should write their notes without the word "septicemia." Use "bacteremia" if there is evidence of bacteria circulating in the blood, and "sepsis" if that impression is support clinically, there are two or more points in the SIRS score, and there is a source of the infection.
• A new wrinkle in ICD-10 is that SIRS is now only applied to noninfectious situations (like burns or trauma). R65.10 refers to SIRS of noninfectious origin without acute organ dysfunction, and R65.11 is with acute organ dysfunction.

— Jon Elion, MD, FACC, is president/founder of ChartWise Medical Systems.