CCS Prep

Key Points to Remember When Coding Infectious Diseases

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Coding for bacteremia, septicemia, sepsis, systemic inflammatory response syndrome (SIRS), severe sepsis and septic shock can be quite perplexing. It is important for the coder to have an understanding of the medical terms, coding guidelines and the AHA Coding Clinics related to these conditions. This article will cover some of the key points on these topics.

Bacteremia

Bacteremia is the presence of bacteria in the blood and denotes only an abnormal laboratory finding. If sepsis symptoms are present, the healthcare provider should be queried for clarification. All coding should be based on the physician's documentation. Coders should not code based on laboratory or radiology findings. Coding issues related to inconsistent, missing or contradictory documentation must be resolved by the provider. Whenever the coder has concerns about the diagnosis, a query should be submitted to the provider for clarification.

Scenario:  The patient presents for a blood test that showed the presence of bacteria in the blood. The provider documented the condition as bacteremia. (Requires one code for the bacteremia.)

Code

790.7

Septicemia

Septicemia is a systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi or other organisms according to I.C.1.b.1.a.i of the Official ICD-9-CM Guidelines for Coding and Reporting. A diagnosis of septicemia requires only one code, usually from category 038.

Scenario:  The patient presents with septicemia due to methicillin-susceptible Staphylococcus aureus (MSSA). (Requires one code for the systemic infection.)

Code

038.11

Sepsis

Sepsis refers to infection with SIRS, according to 1.C.1.b.1.a.iii of the Official ICD-9-CM Guidelines for Coding and Reporting, which does not necessarily have to be proved by positive culture and requires two codes to classify the condition. The first listed code is the systemic infection code and is usually from category 038. The second listed code would be a code for SIRS, which is a systemic response to infection, trauma or burns, or other conditions, with symptoms including fever, tachycardia, tachypnea, and leukocytosis. The code for SIRS is found in category 995. According to guideline I.C.1.b.5 of the ICD-9-CM Official Guidelines for Coding and Reporting, "If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign code 995.92, severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider."  Remember, a code from subclassification 995.9x may not be assigned if the term "sepsis" or "SIRS" is not documented in the medical record.

Scenario:  The patient presents with sepsis due to methicillin-resistant Staphylococcus aureus (MRSA). (Requires two codes: one for the systemic infection and one for the SIRS)

Codes

038.12

995.91

Severe sepsis generally refers to sepsis with associated acute organ dysfunction. If a patient has sepsis with multiple organ dysfunctions, follow the instructions for coding severe sepsis. Either the term sepsis or SIRS must be documented to assign a code from subcategory 995.9- (Coding Clinic, fourth quarter 2006, pg. 155-156). The subcategory 995.9- has a coding note stating to first code the underlying cause of the SIRS. If the underlying cause is not documented, the default code 038.9 should be assigned. The coder should first sequence the code for the underlying cause, followed by the SIRS and then the associated organ dysfunction.

Scenario:  The patient presents with acute kidney failure and is diagnosed with severe sepsis due to the staphylococcal organism. (Requires three codes: one for the systemic infection, one for the SIRS and one for acute renal failure.)

Codes

038.10

995.92

584.9

If the reason for admission is sepsis, severe sepsis or SIRS, with another underlying infection such as pneumonia, cellulitis or a non-specified urinary tract infection, a code for the systemic infection (038.xx, 112.5 etc.) should be assigned first, then code 995.91 or 995.92, followed by the code for the infection. The systemic infection should be sequenced before the localized infection (see guideline I.C.1.b.3 of the ICD-9-CM Official Guidelines for Coding and Reporting).

Scenario:  The patient presents and is diagnosed with severe sepsis due to the MRSA and pneumonia. (Requires three codes: one for the systemic infection, one for the SIRS and one for localized infection.)

Codes

038.12

995.92

486

Septic Shock

Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, represents a type of acute organ dysfunction. Septic shock cannot occur in the absence of severe sepsis. Code 995.92, severe sepsis, must be assigned with code 785.52, septic shock, even if the term severe sepsis is not documented in the record. The "use additional code" note and the "code first the underlying infection" note in the tabular support this guideline (see the Official ICD-9-CM Guidelines for Coding and Reporting guideline I.C.1.b.6.a & b). Also, according to I.C.1.b.6.a, of the Official ICD-9-CM Guidelines for Coding and Reporting, for all cases of septic shock, the code for the systemic infection should be sequenced first, followed by codes for the SIRS, septic shock and any associated organ dysfunction.

Scenario:  The patient presents in septic shock and diagnosed with severe sepsis due to the streptococcal organism. (Requires three codes: one for the systemic infection, one for the SIRS and one for septic shock.)

Codes

038.0

995.92

785.52

Finally, as you prepare for the certification exam one of the most important study guides will be the ICD-9-CM Official Guidelines for Coding and Reporting.

This month's column has been prepared by Nena Scott, MSEd, RHIA, CCS, CCS-P. She is the ICD-10 Educational Trainer for Precyse (www.precyse.com). She is responsible for developing ICD-10 educational material that focuses on each facility's needs based on documentation audits and delivering ICD-10 education to a vast array of health care facilities.

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Key Points to Remember When Coding Infectious Diseases

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