Part B Insider (Multispecialty) Coding Alert

Published on Thu Mar 10, 2005 PDF

Be sure to follow up with docs about confusing terminology

You shouldn't have to be confused about how to bill for sepsis any longer because the latest guidance from the Centers for Medicare and Medicaid Services may make your life easier. 

In its new ICD-9 coding guidance, issued last week, CMS explains that you can't ever list sepsis as a patient's primary diagnosis. If a patient shows signs of sepsis on admission and it meets the definition of a primary diagnosis, then you should first assign the underlying systemic infection code, such as 038.xx (Septicemia) or 112.5 (Candidiasis, disseminate), followed by a code from the sepsis family, 995.9x.

Many providers still don't realize that ICD-9 guidelines no longer treat sepsis and septicemia as the same thing, notes James Kennedy with MA Health Solutions in Nashville, TN. "In the past, sepsis and septicemia were felt to be one and the same," but recent updates from CMS have clarified that they're separate. "Sepsis is the systemic, inflammatory response to a systemic infection, it is not the infection itself," says Kennedy.

Often, physicians will list a diagnosis such as septicemia or bacteremia when the patient actually has sepsis. You won't be able to claim a higher level of medical decision-making unless you can show that the patient had sepsis. If you see lab results showing the patient had fever, high white blood cell count or organ failure such as heart failure, then you should go back to the physician and ask if the patient may have had sepsis.

Likewise, physicians often will use terms such as "urosepsis," which really just means a urinary tract infection, says Kennedy. If the patient has urosepsis plus the signs of a systemic response to the infection, then the patient actually has sepsis. You should encourage physicians to discard this term and either say, "UTI" or "sepsis due to UTI," says Kennedy.

If the patient's blood pressure is low and the patient has perfusion abnormalities, then the patient has septic shock, says Kennedy. CMS says the code for septic shock should always follow the code for the underlying infection and the systemic inflammatory response syndrome code (995.92). For postprocedural sepsis, you should use 998.59 (Other postoperative infections) followed by the sepsis code.