ICD-10 Fact Sheet – Bacteremia/Sepsis/Severe Sepsis/Septic Shock

This month’s Clinical Documentation Improvement tips section will focus on documenting Bacteremia/Sepsis/Severe Sepsis/Septic Shock in ICD-10. To ensure that Quality Metrics, Risk of Mortality, and complexity of care rendered by the physician and the facility are accurately reported, please consider the following information.

The following are not synonymous terms: bacteremia, sepsis, severe sepsis, and septic shock. Please clearly document the most appropriate term in a consistent manner to ensure accurate reporting.

Bacteremia

Note that bacteremia is coded as an abnormal laboratory finding and that this term is not reported as septicemia or sepsis.

Urosepsis

The term “Urosepsis” DOES NOT EXIST IN ICD-10 and cannot be coded - this term will result in a query for documentation clarification regarding diagnosis, underlying cause, etc. (i.e. UTI, Sepsis, or other condition).

The following definitions are offered:

Definitions:

·  Bacteremia – Presence of viable bacteria in the blood.2

·  Sepsis – Sepsis is defined as the presence (probable or documented) of infection together with systemic manifestations of infection. Two or more of the following: Body temperature >38 ◦C or <36◦C; Heart rate >90 beats/min; Respiratory rate >20 breaths/min or hyperventilation with a PaCO2 less than 32 mmHg; White blood cell count >12000/mm3, <4000/mm3, or with >10% immature neutrophils.2

·  Severe Sepsis – acute organ dysfunction or tissue hypoperfusion secondary to infection1

·  Septic Shock – severe sepsis plus hypotension not reversed with adequate fluid resuscitation or blood lactate 4 mmol/L.1

·  Hypotension – sepsis-induced hypotension defined as a systolic blood pressure (SBP) <90 mm Hg, or mean arterial blood pressure (MAP) <70 mm Hg, or a SBP decrease >40 mm Hg.1

Classification/Etiology

The term ‘sepsis’ without further description is classified as sepsis due to unspecified type of Bacteria – if the infecting organism is known or suspected, please state so that the etiology may be correctly classified, such as – anaerobic, candidal, MRSA, gram negative, E. Coli, Fungal, Viral, etc.

State the etiology of the sepsis, i.e., pneumonia, UTI, decubitus ulcer, due to retained medical device, infected surgical site, and so forth.

Please explicitly document any consequences of sepsis, when applicable, such as, but not limited to:

·  Acute Kidney/Renal Failure

·  Acute Tubular Necrosis

·  Acute Respiratory Failure

·  Acute Respiratory Distress Syndrome

·  Critical Illness Myopathy

·  Critical Illness Polyneuropathy

·  Disseminated Intravascular Coagulopathy

·  Encephalopathy

·  Acute Hepatic Failure

·  Septic Shock

·  Multiple Organ Dysfunction Syndrome (document each organ dysfunction)

ICD-9 Code and Diagnosis Terms / ICD-10 Code and Diagnosis Term
038.9: Septicemia, Unspecified / A41.9: Sepsis, unspecifed
038.3: Anerobic Septicemia / A41.4: Anaerobic Sepsis
112.5 : Disseminated Candidiasis / B37.7: Candidal Sepsis
998.32: Sepsis 2/2 Central Catheter / T85.79: Due to Device, Implant
038.9, 995.92, 778.52: Septic Shock / R65.21: Sepsis causing shock
038.12: MRSA causing Sepsis / A41.02: MRSA causing Sepsis
036.2: Meningococcal Sepsis / A39.4: Meningococcal Sepsis

1Crit Care Med 2008 Vol.36, No1. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

2 Chest. 1992 Jun;101(6):1481-3. The ACCP-SCCM consensus conference on sepsis and organ failure.