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Home Health Coding and OASIS Expert

Diagnosis Coding:

Take Care with Sepsis Sequencing

Lead with infection for post-procedural sepsis.

Coding for sepsis was once a rare occurrence in home health, but HHAs are now seeing this diagnosis more frequently. Get the background on sepsis and its related conditions to avoid making some common coding mistakes.

Know the Terms

When it comes to coding for sepsis, there are several related terms you’ll need to know. Make sure you know these definitions before you begin to select a code, says Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates, LLC, CoDR — Coding Done Right and Code Pro University in Denton, Texas.

Sepsis: “The body’s overwhelming and life-threatening response to an infection which can lead to tissue damage, organ failure, and death,” according to the Centers for Disease Control and Prevention.

Septicemia: Bacteria in the blood. Often occurs with severe infections.

Localized infection: An infection that is limited to a specific part of the body and has local symptoms.

Severe sepsis: Sepsis that has caused organ dysfunction or failure.

Follow these Steps

As you code for patients with sepsis, you’ll need to take note of differing sequencing guidelines depending on the situation. You’ll need answers to the following questions before you begin to select your codes:

  • Does the patient have sepsis or severe sepsis? You may need only one code to report sepsis, but you’ll need to list at least two codes for a patient with severe sepsis.
  • Is the causative organism identified?
  • Is the sepsis related to a medical or surgical procedure?

Tip: You’ll code for sepsis and septicemia the same way, Selman-Holman says. For example, you’ll report A40.3 (Sepsis due to Streptococcus pneumoniae) for patients with a diagnosis of Strep pneumoniae. This is the same code you would report for septicemia from of Strep pneumoniae, she says.

Timing Matters with Localized Infections

Sepsis can also occur following a localized infection such as pneumonia or a UTI, but how you’ll sequence your codes depends on when the patient contracts sepsis.

Most often, home health agencies admit patients with sepsis due to a localized infection after the sepsis develops, Selman-Holman says. In these cases, you’ll list the sepsis code first, followed by a code for the localized infection, and then the R65.2- code for severe sepsis, if appropriate.

In the uncommon situation where a patient is admitted with a localized infection that develops into sepsis, you’ll code for the localized infection first.

Coding example: Your patient has sepsis due to Serratia from a UTI. You would list the following codes for this patient, Selman-Holman says:

  • A41.53 (Sepsis due to Serratia) and
  • N39.0 (Urinary tract infection, site not specified).

Expect More Codes with Severe Sepsis

When your patient has sepsis and a related acute organ dysfunction or multiple organ dysfunction, you’ll follow the instructions for coding severe sepsis, Selman-Holman says. This will require a minimum of two codes. If the patient has sepsis and an organ dysfunction and the physician does not seem to relate them in documentation, you should query the physician for additional information.

For patients with severe sepsis, list the underlying systemic infection first, followed by an R65.2- code for severe sepsis, and a third code for any associated organ dysfunction, if appropriate.

Coding example: Your patient has Strep sepsis with acute kidney failure. How would you code for him?

Answer: List the following codes for this patient, Selman-Holman says:

  • A40.9 (Streptococcal sepsis, unspecified);
  • R65.20 (Severe sepsis without septic shock); and
  • N17.9 (Acute kidney failure, unspecified).

This patient has kidney failure caused by strep sepsis. Begin your coding by referencing sepsis due to Streptococcus in the alphabetic index. This leads you to A40.9.

Next, add the code for severe sepsis (R65.20).

Finally, list N17.9 to indicate your patient’s kidney failure.

Look to Complication Codes for Post-procedural Sepsis

Coding for post-procedural sepsis follows different sequencing requirements than other types of sepsis. In this case, you’ll lead with a post-procedural infection code first, and follow up with a sepsis code.

Tip: Post-procedural sepsis must be documented by the physician.

Coding scenario: Your patient has post-procedural sepsis related to an infected surgical wound. Wound and blood cultured positive for Staph aureus that is resistant to penicillins and vancomycin. Skilled nursing will administer an IV antibiotic for 21 days via PICC line. How would you code for this patient?

Answer: List the following codes for this patient, Selman-Holman says:

  • T81.4xxA (Infection following a procedure; initial encounter);
  • A41.02 (Sepsis due to Methicillin resistant Staphylococcus aureus);
  • Z16.21 (Resistance to vancomycin);
  • Z45.2 (Encounter for adjustment and management of vascular access device); and
  • Z79.2 (Long term [current] use of antibiotics).

Begin by listing a code for your patient’s infected surgical wound (T81.4xxA). Choose the 7th character A to indicate active ongoing care because of the continuing IV antibiotics. Follow this with the code for sepsis due to MRSA. Note: For more detail on the new guidelines for selecting the 7th character “A,” see Home Health Coding and OASIS Expert V13N1.

Follow these codes with Z codes to further describe your patient’s condition and the care you’ll provide.