Q&A: Septic shock as principal diagnosis

Q: In what instance would septic shock not be coded as the principal diagnosis? I’ve been under the impression that it should always be principal.

A: Let’s review the Official Guidelines for Coding and Reporting, which coders must follow when assigning codes for an encounter.

According to the Official Guidelines for Coding and Reporting Section I.C.1.d.2(a), septic shock is a type of acute organ dysfunction. For cases of septic shock, the code for the systemic infection should be sequenced first, followed by a code R65.21, Severe Sepsis with Septic Shock. Any additional code(s) for other acute organ dysfunction should also be assigned. As noted in the Tabular List, the code for septic shock cannot be assigned as the principal diagnosis.

The Official Guidelines for Coding and Reporting Section I.C.1.d.1.(b) states that when coding sepsis further specified as severe sepsis or sepsis with acute organ dysfunction, it requires a minimum of two codes: a code for the underlying systemic infection and a code from subcategory R65.2, Severe sepsis.

In this example, assign code A41.9: Sepsis, unspecified organism and code R65.21: Severe Sepsis with Septic Shock the fifth character of “1.” If any other types of acute organ dysfunction are present additional codes would also be needed.

Also review the Official Guidelines for Coding and Reporting Section I.C.1.d.4, which states that when the reason for admission is both sepsis and severe sepsis and a localized infection, such as pneumonia, or cellulitis, a code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis.

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.