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When reviewing sepsis claims, all too often the primary focus is on searching provider documentation for signs and symptoms and/or clinical indicators that support the diagnosis of sepsis, or that support a query regarding the presence of sepsis.

Many times the more subtle details in the sepsis guidelines are overlooked, and sometimes they are not noticed at all. I would like to challenge readers to periodically review and re-review the guidelines in an effort to gain complete understanding of all aspects of sepsis coding, and consider the following sepsis coding scenarios.

Sepsis as Principal Diagnosis

Is sepsis always sequenced as the principal diagnosis when it is present on admission? Some may say yes, because after all, that’s what is stated in the official coding guidelines. However, my answer to this question is no, not always. I believe that there are very few absolutes in coding, and the sepsis guidelines are a good example of this. ICD-10-CM Official Coding Guidelines for Coding and Reporting direct us that “if severe sepsis is present on admission and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List.” We are further directed that, “if the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List.” 

You may be thinking, “so what? These are the same guidelines we have always had, and I know that sepsis is sequenced first when it is present on admission!” Not so fast.

Consider this scenario: A patient presents to the hospital with shortness of breath and is admitted with an acute exacerbation of systolic congestive heart failure. Patient is started on BiPAP for breathing difficulties, with increased IV Lasix and chest X-ray performed, which confirmed acute exacerbation of congestive heart failure, along with blood cultures drawn on admittance. Patient is also discovered to have MSSA sepsis by positive blood culture. 

The patient is started on antibiotics to treat MSSA sepsis. During the admission, the patient’s breathing difficulties increased and the patient ended up in acute respiratory failure, requiring intubation. At the end of patient’s admission, the acute exacerbation of systolic congestive heart failure was felt to be the cause of patient’s shortness of breath, and ultimately, respiratory failure. Would the principal diagnosis in this scenario be sepsis since it was present on admission? According to the guidelines above, sepsis would be the appropriate principal diagnosis if it is the reason the patient is admitted, and meets the definition of principal diagnosis. In this scenario, however, the patient was admitted for shortness of breath, which was deemed to have been caused by an acute exacerbation of systolic congestive heart failure, and the focus of patient’s treatment was the heart failure exacerbation – which means that sepsis does not meet the definition of principal diagnosis and would not be sequenced first.  

Sepsis without Positive Blood Cultures and Noninfectious Sepsis

ICD-10-CM Official Guidelines for Coding and Reporting directs us that when sepsis or severe sepsis is documented as being associated with a noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious condition should be sequenced first, followed by the code for the resulting infection. In other words, a patient admitted for a burn injury and severe sepsis was deemed to have occurred due to the burn injury, the burn injury would be sequenced as principal diagnosis. Let’s apply this guideline to the following scenario.

A patient is admitted for a GI bleed and septic shock. Patient’s blood cultures have remained negative for any organism throughout the stay. Patient’s documentation does not specifically state the cause of patient’s shock. Would sepsis be the appropriate principal diagnosis, or would GI bleed be the appropriate principal diagnosis? Which sepsis guideline would apply – the severe sepsis associated with a noninfectious process guideline, or the severe sepsis (infectious) guideline? 

The answer would depend on what additional information is obtained from the provider. However, it is important to note here that the absence of positive blood cultures in a patient with severe sepsis does not equal noninfectious sepsis.

We are directed by ICD-10-CM Official Guidelines for Coding and Reporting that even though negative or inconclusive blood cultures do not negate a diagnosis of sepsis in patients with clinical evidence of the condition; providers should be queried under these circumstances. So in this scenario, which is an actual real-life scenario, the provider would need to be queried as to the cause of patient’s septic shock and whether it was a noninfectious source (possibly patient’s GI bleed) or a suspected infection before an appropriate principal diagnosis could be chosen.


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