Sepsis is a potentially life-threatening condition that can result from an infection. Accurate coding of sepsis is important for patient care and appropriate reimbursement. Here are some tips for coding sepsis in ICD-10:
- Understand the definition of sepsis: Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection.
- Identify the site and cause of infection: In order to code sepsis, you need to identify the site and cause of infection. The site of infection can be identified by the provider’s documentation, as can the cause of the infection.
- Know the ICD-10 codes for sepsis: The ICD-10 codes for sepsis are A41.0, A41.1, and A41.9. These codes are used to report sepsis due to bacterial, viral, or unspecified origin.
- Use additional codes when necessary: Additional codes may be necessary to report any associated conditions or complications. For example, if a patient with sepsis also has acute respiratory failure, you would use codes J96.00 (Acute respiratory failure, unspecified) and J18.9 (Pneumonia, unspecified organism).
- Follow sequencing rules: When reporting sepsis along with other conditions, follow the sequencing rules to ensure that the primary reason for the encounter is listed first.
- Understand the coding guidelines: The coding guidelines for sepsis specify that the codes should be based on the provider’s documentation of the condition.
- Be aware of the clinical indicators of sepsis: Clinical indicators of sepsis include fever, hypothermia, tachycardia, tachypnea, altered mental status, and signs of systemic inflammation. Familiarize yourself with these indicators to help identify and accurately code sepsis.
Remember, accurate coding of sepsis is essential for patient care and appropriate reimbursement. Use these tips to help ensure that sepsis is accurately coded and reported in ICD-10.