Q&A: Sepsis, septic shock, still cause for query confusion

Q: If the physician writes septic shock instead of sepsis do I need to query for sepsis or is this an integral part and sepsis would be the principal diagnosis and the septic shock would be secondary, making it a MCC?

A: You are not alone if you find the coding of sepsis to be challenging. In the case you describe above the documentation of septic shock would support both codes for the septicemia and the 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 Official 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- Chapter 1: Certain Infectious and Parasitic Diseases. I always suggest that new CDIs 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. For some additional reading please take a look at some articles from the ACDIS website.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.