ICD-10-CM Specific Coding Guidelines - Sepsis

[Music]

ch

ch

[Music]

[Music]

[Music]

ch

[Music]

[Music]

oh

[Music]

[Music]

section which is on sepsis yes sepsis is

also very important

uh part in the chapter one and it has

got some guidelines as well to review so

cus what is a sepsis a sepsis is a

potential lifethreatening condition

caused by body's response to an

infection so what it happens it usually

starts with a local in local uh

infection and this infection will be

caused by a bacteria so as you can see

in the image which has been provided so

so in the step two the bacteria will

enter into the bloodstream and naturally

what does the body do body will respond

to that bacteria and our immune system

will fight back the infection and in a

worst case scenario the bacteria and

immune cells might spread throughout the

body and it will cause an uncontrolled

inflammation which might lead to an even

organ damage and even death if left unre

so that is what sepsis all about and it

is really a serious condition which

requires a immediate medical attention

so what is severe sepsis a severe sepsis

is the sepsis with an acute organ

dysfunction and what is a septic shock

it is a form of an sever sepsis where

organ dysfunction involves

cardiovascular system so these are more

severities of the

sepsis so coming to our coding part

underlying organism the sepsis and CVS

is required to require a code to

identify the systemic infection yes if

you find a scenario on sepsis first

thing which we have to look is whether

the organism uh which caus the sepsis is

known or not so if the organm is

unknown we would code a

41.9 and if the organism is known it

will depends on the last few characters

the last two characters will depend uh

will be specific for the uh infection

which is C so a41 point the remaining

two characters it will Define the

organism that cause the sepsis and the

guideline number is C1 T1

A3 so let's move on to the next

guideline on S sepsis with acute organ

function and this requires minimum of

two codes and your sequency order is as

follows code first the underlying

organism as I said in the previous slide

if the organism is known it would be a41

last two characters would be more

specific for the organism and a

41.9 for asepsis unknown organism

unknown ctive organism and the second

code second code would be r65

5.2 Z would be for the c CVS sepsis

without septic shock and

r65.2 one would be for S sepis with

septic shock so it depends upon the

documentation and important thing for

you all to note here is that uh this R

64.2 ICD is never sequenced first it

would be sequenced only after uh the

organism or the sepsis

Cod

and the third code for the organ

dysfunction so if the as you can see the

C sepsis with organ dysfunction acute

organ dysfunction is a title so if the

cious sepsis is with organ dysfunction

the third code would be for the organ

dysfunction that involved and the

guideline for this is C1

d1b in your book ICD book now let's move

on to the next guideline see D1 D2 setic

shock with organ

dysfunction and this one also required

minimum of two quotes code first the

underlying

organism

a41 or a

41.9 if organm is unknown code second

r65.21 for septic shock once again

r65.21 is not sequenced first it's never

sequenced first

uh the third code would be for the organ

dysfunction or kidney failure if

involved any kid if it involves any

kidney failure and fourth code would be

for any Associated organ

dysfunction so these are the guidelines

coding septic sepsis I'm sorry

sepsis now I think it's time to test

your knowledge on sepsis and and the

related guideline so here we are having

a question what code are assigned your

options are a 41.9

r65.21 option b a 40.1 J1 15.3

r65.20 option C A 40.1 J1 15.3 option D

A 41.9 J1 15.3

r65.21 a patient admitted to the

hospital with stripto coal Group B

pneumonia with severe sepsis what ICD

codes are assigned so coders I would

give you around two minutes to solve

this scenario and we will be coming back

and

discussing the

answers

okay what is at time and I was having

look into the chat to see your answers

so I see that there's mix mixed response

in the chat so this is going to be tach

moment let's highlight the keywords for

this scenario strepto coal groy

pneumonia with sever

sepsis so coders let me ask you a

question what is the diagnosis which we

are having the patient is having a

severe

sepsis and it's a strepto cocal B

pneumonia with seious sepsis that's a

final diagnosis with the patient is

having so we are having a local

infection as well so if you look into

the guideline see 1 D4 it State sepsis

or sever sepsis with a localized

infection yes we are having a localized

infection yes we are having a c sepsis

as well under these condition what

should we

do the patient admitted for a sepsis

with localized infection the underlying

systemic infection is sequenced first

then the loc localized infection then if

if applicable the code for uh cvsis are

65 .20 and finally organ dysfunction so

this is your sequencing order for this

scenario so let me

look is the sepsis type specified is

organism specified or

not let me have a look into the

chat is organism the hi is organism

costive organs mentioned in our scenario

or not yes sir I see the answer so yes

specified exactly so a

41.9 what is a 41.9 coding for a 41.9 is

coding for a sepsis unspecified organism

while in our scenario it's mentioned

stal B pneumonia with s sepsis so the

stral B Group B is the

specified I'm sorry for my tone is a

specified organism so a41 9 a 41.9 is

the wrong answer so I can eliminate

option A and option D

here so that's El that's eliminated the

remaining two options are B and

C looking into the sequencing order now

I have to code for the first for the

sepsis with specified organism that

would be a 40.1 yes sepsis due to

streptococus Group B that's done what

comes next next comes a localized

infection and that would be pneumonia

right j8 J

15.3 and what comes next yes over

here next comes R

65.2 and we are also having a s sepsis

in our scenario so that would be a 65.2

three and option C is not coding for

csis while it was necessary because

scenario states that we are having a

strepto cocal Group B pneumonia with

sever

sepsis so the sequencing order would be

a

40.1 J1

15.3 and

r65.20 which is the code for C sepsis

without septic

shock how are you feeling about that

one