Mastering the Coding Challenge- How to Accurately Code Severe Sepsis and Septic Shock in Medical Records

How to Code Severe Sepsis with Septic Shock

Severe sepsis and septic shock are critical conditions that require immediate medical attention. Proper coding of these conditions is essential for accurate diagnosis, treatment planning, and billing. In this article, we will discuss how to code severe sepsis with septic shock, ensuring healthcare professionals understand the correct ICD-10-CM codes to use.

Understanding Severe Sepsis and Septic Shock

Severe sepsis is a life-threatening condition that occurs when the body’s response to an infection injures its own tissues and organs. It is characterized by a systemic inflammatory response syndrome (SIRS) with at least one of the following criteria: body temperature greater than 38.3°C (101°F) or less than 36°C (96.8°F), heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute, or white blood cell count greater than 12,000 cells/mm³ or less than 4,000 cells/mm³ or more than 10% immature cells.

Septic shock is a more severe form of sepsis, characterized by low blood pressure and a narrow pulse pressure, which can lead to organ failure. It is considered a medical emergency and requires immediate treatment.

ICD-10-CM Coding for Severe Sepsis and Septic Shock

To code severe sepsis with septic shock, healthcare professionals should use the following ICD-10-CM codes:

– B94.8: Sepsis unspecified
– B94.9: Sepsis, unspecified, with septic shock

If the patient has a known source of infection, additional codes should be used to indicate the specific source. For example:

– B94.81: Sepsis due to pneumonia
– B94.82: Sepsis due to urinary tract infection
– B94.83: Sepsis due to skin and subcutaneous tissue infection

It is important to note that the primary diagnosis should be the source of infection, followed by the code for sepsis with septic shock.

Additional Considerations

When coding for severe sepsis and septic shock, healthcare professionals should also consider the following:

– The presence of any comorbid conditions that may contribute to the patient’s condition, such as diabetes, heart disease, or renal failure.
– The use of antibiotics or other treatments, which should be coded separately.
– The patient’s prognosis and any complications that may arise during treatment.

By using the correct ICD-10-CM codes for severe sepsis with septic shock, healthcare professionals can ensure accurate diagnosis, treatment planning, and billing. This will ultimately lead to better patient care and outcomes.