Easy tips to code Severe Sepsis icd 9 code

Coding of SIRS (systemic inflammatory response syndrome) and severe sepsis icd 9 code is a challenge. There has been lot of confusion while coding sepsis. It all depends on the documentation in the report and how to apply them on patients.  We have guidelines to code severe sepsis icd 9 code. Sepsis, severe sepsis, and SIRS are the major diagnosis used in icd 9 coding guidelines.
Sepsis is a combination of both presence of infection and systemic inflammatory response. Severe sepsis is combination of acute organ dysfunction along with sepsis. Sepsis associated with acute organ dysfunction comes in severe sepsis category. Next, come the septic shock in which we have severe sepsis associated with circulatory failure. Therefore, if we define these three terms in short it will be as follows. 
Sepsis: Infection + Systemic inflammatory response syndrome (SIRS due to infection)
Severe sepsis: Sepsis + Acute single or multiple organ dysfunctions
Septic shock: Severe sepsis + acute circulatory failure

Coding severe sepsis icd 9 code

Coding of sepsis, severe sepsis, and Septic shock requires two codes. The primary code is the cause, such as infection or trauma, followed by the 995.9 series codes. 995.9 series are SIRS codes. When we have sepsis or severe sepsis mention in the report, we will use secondary code 995.91 for sepsis and 995.92 for severe sepsis. So, we know from this that sepsis and severe sepsis icd 9 code are 995.91 and 995.92 respectively. The primary code will be the systemic infection code form 038 series followed by the sepsis or severe sepsis code. Suppose if we have to code streptococcal sepsis and severe sepsis we will code
Sepsis: 038.0, 995.91
Severe sepsis: 038.0, 995.92

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If the systemic infection is not specified, we can code 038.9 as primary followed by 995.91 or 995.92. Codes for category 995.9 should not be assigned primary dx code.
For septic shock, we have to add one more code with severe sepsis. Since, septic shock is a combination of severe sepsis and acute circulatory failure, we will code severe sepsis first followed by septic shock code 785.52.So finally the septic shock code will be as follows
Septic shock: 038.9, 995.92, 785.52
An additional icd code for acute organ dysfunction should also be assigned.

Read also: ICD 9 code for Cellulitis of leg

Severe sepsis icd 10 code

Sepsis updated icd 10 coding is little different. Here we are using only one code for sepsis and two codes for severe sepsis. For sepsis, we are directly coding A41 series codes for sepsis with specified organism. For unspecified organism sepsis, we are use A41.9.
For coding severe sepsis with an associated organ dysfunction, we have to code two codes. Primary code will be the underlying infection code followed by severe sepsis code. So, if we have to severe sepsis of unspecified infection we will code as
A41.9, R65.20
If they specify the organ dysfunction, we can go ahead and code organ dysfunction code. So, if there is severe sepsis with acute respiratory failure (J96.0) we will code
A41.9, R65.20, J96.0
Here in icd 10 we have to fewer codes for sepsis compared to icd 9. For Septic shock, we have to follow same but we have a different secondary icd code. The primary code will be for the underlying infection, followed by severe sepsis with septic shock icd code R65.21. So, if an unspecified infection with septic shock is documented we can code
A41.9, R65.21
Any acute organ dysfunction present should also be assigned.

Read also: ICD 9 code for Hyperkalemia

When not to code severe sepsis icd 9 code

When there is no relation between acute organ dysfunction and severe sepsis, do not code severe sepsis icd 9 code 995.92. Medical documentation should indicate any relation between organ dysfunction and severe sepsis to code 995.92. If the documentation is not clear to understand, please query with the provider.
When severe sepsis is associated with the non-infectious process like trauma, which lead to sepsis or severe sepsis, in such case primary code will the non-infectious condition. The primary code will be followed by the systemic infection and sepsis 995.91 or severe sepsis 995.92
Never code 995.91 and 995.92 together, only code any one of them either sepsis 995.91 or severe sepsis 995.92.
Hope, you won't have confusion to code severe sepsis icd 9 code in future. If you like the article do share it.

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