Q: If the physician writes septic shock instead of sepsis, do I need to query for sepsis? Is this an integral part of the diagnosis and sepsis would be the principal diagnosis, with septic shock a secondary diagnosis, making it an MCC?
A: You are not alone if you find the coding of sepsis to be challenging. In the case you describe, the documentation of septic shock would support both codes for septicemia and severe sepsis. Septic shock cannot occur without sepsis and severe sepsis being present.
You would need to add codes for the underlying condition (local infection), as well as codes for the organ dysfunction resulting from the sepsis that support the presence of severe sepsis. It is also a good practice to assign the code for causal organism if known.
The septic shock would provide the MCC as the secondary diagnosis.
The ICD-9-CMOfficial Guidelines of Coding and Reporting specifically outline the coding practices for sepsis, severe sepsis, and septic shock very clearly in the chapter specific coding guidelines for Chapter 1, Infectious and Parasitic Diseases. I always suggest that new CDIs and coding professionals take time to read the guidelines to assist with the special considerations related to this diagnosis.
Again, you are not the only one who has struggled with this difficult topic.
Editor’s note: Laurie Prescott, MSN, RN, CCDS, a CDI education specialist for HCPro, a division of BLR, in Danvers, Massachusetts, answered this question.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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