Coding E. Coli Septicemia with Severe Sepsis and Acute Renal Failure
THE FOLLOWING TABLE compares coding E. coli septicemia in ICD-9-CM and ICD-10-CM from the case study of the
67-year-old woman.
CODES ASSIGNED
CODE COMPARISONS
ICD-9-CM
038.42, Septicemia due to E. coli
995.92, Severe sepsis
584.9, Acute kidney failure, unspecified
The severe sepsis code is located in tabular list,
chapter 17, “Injury and Poisoning.”
ICD-10-CM
A41.51, Sepsis due to E. coli
R65.20, Severe sepsis without septic shock
N17.9, Acute kidney failure, unspecified
The term sepsis has replaced septicemia throughout
the tabular list, chapter 1, “Certain Infectious and
Parasitic Diseases.”
REQUIRED DOCUMENTATION
The extent of the infection (i.e., sepsis, severe
sepsis)
Severe sepsis: if the causal organism is not
documented, code 038.9, Unspecified septicemia,
is assigned.
The associated acute organ dysfunction(s)
Severe sepsis code is located in tabular list, chapter
18, “Symptoms, Signs, and Abnormal Clinical and
Laboratory Findings.” Severe sepsis code specifies
without shock.
The extent of the infection (i.e., sepsis, severe
sepsis)
Sepsis: the underlying systemic infection. If the type
of infection or causal organism is not documented,
code A41.9, Sepsis unspecified, is assigned.
Severe sepsis: the underlying systemic infection. If
the causal organism is not documented, code A41.9,
Sepsis unspecified, is assigned.
The associated acute organ dysfunction
culture returned with E. coli, resistant to TMP/SMX. She was
changed to IV ciprofloxacin, after which she improved rapidly.
Upon discharge, the physician documented the principal
diagnosis as E. coli septicemia, with severe sepsis and acute
renal failure. The proper code assignment is shown in the table
above.
Due to the complex nature of SIRS, sepsis, and severe
sepsis, physician documentation is essential in accurate code
assignment. In some instances it may require a physician
query prior to accurate code assignment.
Infections in the urinary tract, SIRS, sepsis, and severe
sepsis can be coding challenges for all involved. Maintaining
a supportive relationship between coding professionals and
physicians through ongoing communication and clinical
documentation improvement programs has proven beneficial
to assist with such challenges.
Working together helps ensure the physician documentation
reflects the quality of patient care provided. Clinical
documentation that is precise and thorough can also provide
a defense for regulatory compliance reviews, including the
Recovery Audit Contractor, and will contribute to a successful
ICD-10-CM/PCS transition. ¢
Notes
1. National Kidney and Urologic Diseases Information
Clearinghouse. “Your Urinary System and How It Works.”
August 2007. Available online at http://kidney.niddk.nih.
gov/kudiseases/pubs/yoururinary.
2. Bone, RC, RA Balk, FB Cerra, et al. “Definitions for
Sepsis and Organ Failure and Guidelines for the Use of
Innovative Therapies in Sepsis.” Chest 101 (1992): 1644–
55. Available online at http://chestjournal.chestpubs.
org/content/101/6/1644.full.pdf.
3. Levy, MM, MP Fink, JC Marshall, et al. “2001 SCCM/
ESICM/ACCP/ATS/SIS International Sepsis Definitions
Conference.” Critical Care Medicine 31 (2003): 1250–
56. Available online at www.srlf.org/data/Upload/
Consensus/pdf/293.pdf.
Resources
National Centers for Health Statistics. “ICD-10-CM Official
Guidelines for Coding and Reporting 2010.” Available online
at https://www.cms.gov/ICD10/Downloads/7_Guidelines10
cm2010.pdf.
National Centers for Health Statistics. “ICD-9-CM Official
Guidelines for Coding and Reporting.” Available online at
www.cdc.gov/nchs/data/icd9/icdguide09.pdf.
Ginger Boyle ( gbboyle@srhs.com) is clinical faculty for the Spartanburg
Family Medicine Residency Program and an assistant professor with the
South Carolina AHEC/MUSC School of Medicine. Karen Kostick (karen.
kostick@ahima.org) is a practice resources specialist at AHIMA.
