Wiki Severe Sepsis with Septic Shock - documented

[Mindy Davis]

If severe sepsis with septic shock is documented as the dx in the disposition but no underlying infection or acute organ dysfunction is noted (because cultures aren't back) how would I need to code this chart. Is there a code for unknown infection?

 

[mitchellde]

You should read the guidelines for sepsis coding and sequencing.
As far as the coding for the organism, here is what they state:
For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism.
A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented.

 

[Mindy Davis]

Thank you! I wish the ICD-10 would have reference the page # that the guidelines are on. it would save a lot of time and confusing.

 

[mitchellde]

Just know that the guidelines have a good structure. You start with conventions and then general, then chapter guidelines which are in the same order as the tabular chapters. Infections first all the way through to,the Z last. Many code books now put each chapters guidelines at the beginning of each chapter. The one I use does this, and it does make it easier.