Demystifying Coding for SIRS, Sepsis, Severe Sepsis and Septic Shock
One of the more challenging coding scenarios is the accurate coding of systemic inflammatory response syndrome (SIRS) and sepsis. Septicemia and Sepsis are often used interchangeably by physicians; however, they are not the same.
- Septicemia refers to a systemic disease identified by bacteria, viruses, fungi, or other organisms in the blood.
- Systemic inflammatory response syndrome (SIRS) refers to the systemic response to infection, trauma, burns, or other cause such as cancer with symptoms that include fever, tachycardia, tachypnea, and leukocytosis.
- Sepsis is SIRS due to an infection that can originate anywhere in the body and be triggered by a bacterial, viral, parasitic, or fungal infection
- Severe sepsis is SIRS due to septicemia with organ dysfunction which may be cardiovascular, renal, respiratory, hepatic, central nervous system, or metabolic acidosis.
- Septic shock is associated with severe sepsis and circulatory failure or acute organ dysfunction.
Frequently, a patient is suspected of having septicemia and is treated for the condition even though the blood cultures may not be positive. Although blood is usually drawn for culturing during the initial workup, treatment must be started quickly, often before the results of the culture are known. Even when a patient shows clinical evidence of septicemia, the blood culture may be negative due to the difficulty of culturing certain organisms from blood, the effects of growth-inhibitory factors in the blood, or the initiation of specific antibiotic therapy before laboratory test samples were taken. Negative or inconclusive blood cultures do not preclude a diagnosis of septicemia in patients with clinical evidences of the condition.
How to Code SIRS, Sepsis, Severe Sepsis and Septic Shock
Careful review of the medical record, understanding the pathology of the infections in the Septic Continuum, and following the coding guidelines are necessary to ensure accurate code assignment.
Most septicemias are classified to category 038, with fourth and fifth digits indicating the responsible organism. Staphylococcal septicemia uses the fifth digit to indicate that the infection is due to either Staphylococcus aureus (038.11) or other specified type of Staphylococcus (038.19). Organisms are sometimes transferred to other tissue, where they may spread infection to another site and lead to such conditions as arteritis, meningitis, and pyelonephritis.
A minimum of two codes are required when coding sepsis: a code for the underlying systemic infection and a code from subcategory 995.9x for SIRS. The general coding guidelines instruct us to sequence the code for the underlying condition before the SIRS code.
When coding sepsis and severe sepsis, we must code the systemic infection first (such as 038.xx) and either 995.91 for sepsis or 995.92 for severe sepsis. There also needs to be an additional code for cases of severe sepsis to identify the acute organ dysfunction. If known, a code for the local infection is also assigned.
When coding for septic shock, the code for the systemic infection should be sequenced first followed by either 995.92 for severe sepsis and 785.52 for septic shock, or 998.02 for a postoperative septic shock. Any other acute organ dysfunction should also be coded.
Due to the complex nature of SIRS, sepsis, and severe sepsis, physician documentation is essential in accurate code assignment. Do not code on the basis of laboratory or radiological findings alone. ICD-9-CM code assignment issues related to inconsistent, missing, conflicting or unclear documentation must be resolved by the provider. In some instances it may require a physician query prior to accurate code assignment.
- Accurate Documentation is Essential – Knowing When to Query your Providers - September 30, 2015
- Breathe Easy: Coding Respiratory Failure in the Inpatient Setting - August 4, 2015
- Facility Discharge Status Codes – PACT Policy Update - May 28, 2015