Q&A: Viral sepsis versus viral sepsis syndrome

Q: I am a little confused about sepsis coding. I understand that the documentation of “sepsis syndrome” should be queried, but when should “viral sepsis” versus “viral sepsis syndrome” be used?

A: “Viral sepsis” is very different from “viral sepsis syndrome” and the coding will also differ.

CDI specialists should pay close attention to the verbiage associated with sepsis “syndrome” and determine if the “syndrome” is linked to anything else other than the sepsis.

For example, “viral sepsis syndrome” would not be coded because the “syndrome” is associated with the sepsis and there is no ICD-10 code for “sepsis syndrome.” Sepsis with “viral syndrome,” however, is a very different situation and can be coded.

Because the syndrome is linked with the virus in this particular scenario, sepsis can be coded as A41.89, Other specified sepsis, and the virus is linked to the syndrome resulting in ICD-10 code B34.9, Viral infection, unspecified.

According to Coding Clinic, third quarter 2016, p. 8, “sepsis secondary to viral syndrome” would be coded using the following codes

• A41.89, Other specified sepsis, for the viral sepsis
• B34.9, Viral infection, unspecified, for the viral syndrome

Coding Clinic goes on to say that “in this case, code B34.9 is assigned rather than code B97.89, since ‘syndrome, virus,’ is specifically indexed to B34.9. Code A41.89 is the best available option to capture the concept of sepsis, since ICD-10-CM does not have a specific code for viral sepsis. ‘Sepsis, specified organism, not elsewhere classified, is indexed to code A41.89’.”

 Editor’s note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist with HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.