1. Definitions
1.1. SIRS (Systemic Inflammatory Response Syndrome) is defined as the presence of two or more of the following four symptoms
1.1.1. Body Temperature Alterations: - Fever (Body Temperature more than 100.4 degrees Fahrenheit) or - Hypothermia (Body temperature less an 96.8 degrees Fahrenheit)
1.1.2. Tachycardia: Heart rate of more than 90 beats per minute
1.1.3. Tachypnea: - Respiration rate of more than 20 breaths per minute or - Arterial carbon dioxide tension (PaCO2) less than 32 mmHg
1.1.4. Abnormal white cell count: - Leukocytosis (WBC > 12,000uL) or - Leukopenia (WBC < 4,000uL) or - 10% immature [band] forms
1.2. Sepsis = Infection + SIRS
1.3. Severe Sepsis = Sepsis + Associated Organ Dysfunction
1.4. Septic Shock = Sepsis + Circulatory Failure
2. Negative or inconclusive blood cultures
2.1. Query the provider for additional information
3. Urosepsis
3.1. Query the provider for clarification
4. SIRS
4.1. Without subsequent infection
4.1.1. Without associated organ dysfunction
4.1.1.1. Code underlying condition
4.1.1.1.1. i.e., S31.823A, Puncture wound without foreign body of left buttock initial encounter
4.1.1.1.2. i.e., K85.9, Acute pancreatitis, unspecified
4.1.1.2. Code R65.10, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction
4.1.2. With organ dysfunction but documentation is unclear if the dysfunction is related to the noninfectious process or some other medical condition
4.1.2.1. Query the provider for clarification
4.1.3. With associated organ dysfunction
4.1.3.1. Code underlying condition
4.1.3.1.1. i.e., S31.823A, Puncture wound without foreign body of left buttock initial encounter
4.1.3.1.2. i.e., K85.9, Acute pancreatitis, unspecified
4.1.3.2. Code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction
4.1.3.3. Code for any associated organ dysfunction(s)
4.1.3.3.1. i.e., J96.00, Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
4.1.3.3.2. i.e., N19, Unspecified kidney failure
4.2. With subsequent infection
4.2.1. See appropriate category of sepsis coding listed below
4.2.1.1. Sepsis
4.2.1.2. Sepsis due to:
4.2.1.3. Sepsis Complicating Abortion, Pregnancy, Childbirth, & the Puerperium
4.2.1.4. Newborn Sepsis
5. Sepsis
5.1. Without associated organ dysfunction
5.1.1. Causal organism known
5.1.1.1. Code underlying systemic infection
5.1.1.1.1. i.e., A40.1, Sepsis due to streptococcus, group B
5.1.1.1.2. i.e., G00.9, Bacterial meningitis, unspecified
5.1.2. Causal organism unknown
5.1.2.1. Code A41.9, Sepsis, unspecified organism
5.2. With organ dysfunction but documentation is unclear if the dysfunction is related to the sepsis or some other medical condition
5.2.1. Query the provider for clarification
5.3. With associated organ dysfunction (aka Severe Sepsis)
5.3.1. Unknown organ dysfunction
5.3.1.1. Causal organism known
5.3.1.1.1. Code underlying systemic infection
5.3.1.1.2. Code R65.20, Severe sepsis without septic shock
5.3.1.2. Causal organism unknown
5.3.1.2.1. Code A41.9, Sepsis, unspecified organism
5.3.1.2.2. Code R65.20, Severe sepsis without septic shock
5.3.2. Known organ dysfunction
5.3.2.1. Without circulatory failure
5.3.2.1.1. Causal organism known
5.3.2.1.2. Causal organism unknown
5.3.2.2. With circulatory failure (aka Septic Shock)
5.3.2.2.1. Unrelated to a procedure or surgery
5.3.2.2.2. Following a procedure or surgery (aka Postprocedural septic shock)
6. Sepsis due to:
6.1. Localized infection
6.1.1. Sepsis present at time of encounter/admission
6.1.1.1. Without associated organ dysfunction
6.1.1.1.1. Causal organism known
6.1.1.1.2. Causal organism unknown
6.1.1.2. With organ dysfunction but documentation is unclear if the dysfunction is related to the sepsis or some other medical condition
6.1.1.2.1. Query the provider for clarification
6.1.1.3. With associated organ dysfunction (aka Severe Sepsis)
6.1.1.3.1. Unknown organ dysfunction
6.1.1.3.2. Known organ dysfunction
6.1.2. Documentation is unclear when sepsis developed
6.1.2.1. Query the provider for clarification
6.1.3. Sepsis NOT present at time of encounter/admission
6.1.3.1. Does NOT develop sepsis during encounter/admission
6.1.3.1.1. Code localized infection only
6.1.3.2. Develops sepsis during encounter/admissoin
6.1.3.2.1. Without associated organ dysfunction
6.1.3.2.2. With organ dysfunction but documentation is unclear if the dysfunction is related to the sepsis or some other medical condition
6.1.3.2.3. With associated organ dysfunction (aka Severe Sepsis)
6.2. Postprocedural infection
6.2.1. Following infusion, transfusion, or therapeutic injection
6.2.1.1. Due to central venous catheter
6.2.1.1.1. Bloodstream infection
6.2.1.1.2. Local infection
6.2.1.1.3. Other infection
6.2.1.1.4. Unspecified infection
6.2.1.2. Not due to central venous catheter
6.2.1.2.1. Acute infection
6.2.1.2.2. Infection not specified as acute
6.2.2. Following immunization
6.2.2.1. Without associated organ dysfunction
6.2.2.1.1. Causal organism known
6.2.2.1.2. Causal organism unknown
6.2.2.2. With organ dysfunction but documentation is unclear if the dysfunction is related to the sepsis or some other medical condition
6.2.2.2.1. Query the provider for clarification
6.2.2.3. With associated organ dysfunction (aka Severe Sepsis)
6.2.2.3.1. Unknown organ dysfunction
6.2.2.3.2. Known organ dysfunction
6.2.3. Following obstetrical surgical wound
6.2.3.1. Without associated organ dysfunction
6.2.3.1.1. Causal organism known
6.2.3.1.2. Causal organism unknown
6.2.3.2. With organ dysfunction but documentation is unclear if the dysfunction is related to the sepsis or some other medical condition
6.2.3.2.1. Query the provider for clarification
6.2.3.3. With associated organ dysfunction (aka Severe Sepsis)
6.2.3.3.1. Unknown organ dysfunction
6.2.3.3.2. Known organ dysfunction
6.2.4. Following procedure
6.2.4.1. Without associated organ dysfunction
6.2.4.1.1. Causal organism known
6.2.4.1.2. Causal organism unknown
6.2.4.2. With organ dysfunction but documentation is unclear if the dysfunction is related to the sepsis or some other medical condition
6.2.4.2.1. Query the provider for clarification
6.2.4.3. With associated organ dysfunction (aka Severe Sepsis)
6.2.4.3.1. Unknown organ dysfunction
6.2.4.3.2. Known organ dysfunction
6.3. Noninfectious process
6.3.1. Without associated organ dysfunction
6.3.1.1. Causal organism known
6.3.1.1.1. Principal Diagnosis: Noninfectious Process
6.3.1.1.2. Principal Diagnosis: Infection (Sepsis)
6.3.1.2. Causal organism unknown
6.3.1.2.1. Principal Diagnosis: Noninfectious Process
6.3.1.2.2. Principal Diagnosis: Infection (Sepsis)
6.3.2. With organ dysfunction but documentation is unclear if the dysfunction is related to the sepsis or some other medical condition
6.3.2.1. Query the provider for clarification
6.3.3. With associated organ dysfunction (aka Severe Sepsis)
6.3.3.1. Unknown organ dysfunction
6.3.3.1.1. Causal organism known
6.3.3.1.2. Causal organism unknown
6.3.3.2. Known organ dysfunction
6.3.3.2.1. Without circulatory failure
6.3.3.2.2. With circulatory failure (aka Septic Shock)
7. Sepsis Complicating Abortion, Pregnancy, Childbirth, & the Puerperium
8. Newborn Sepsis
8.1. Without associated organ dysfunction
8.1.1. Causal organism known
8.1.1.1. Bacterial
8.1.1.1.1. Streptococcus
8.1.1.1.2. Staphylococcus
8.1.1.1.3. Escherichia coli
8.1.1.1.4. Anaerobes
8.1.1.1.5. Other
8.1.1.2. Other (Viral, Fungal, etc)
8.1.1.2.1. Code underlying systemic infection
8.1.2. Causal organism unknown
8.1.2.1. Code P36.9, Bacterial sepsis of newborn, unspecified
8.2. With organ dysfunction but documentation is unclear if the dysfunction is related to the sepsis or some other medical condition
8.2.1. Query the provider for clarification
8.3. With associated organ dysfunction (aka Severe Sepsis)
8.3.1. Unknown organ dysfunction
8.3.1.1. Causal organism known
8.3.1.1.1. Bacterial
8.3.1.1.2. Other (Viral, Fungal, etc)
8.3.1.2. Causal organism unknown
8.3.1.2.1. Code P36.9, Bacterial sepsis of newborn, unspecified
8.3.1.2.2. Code R65.20, Severe sepsis without septic shock
8.3.2. Known organ dysfunction
8.3.2.1. Without circulatory failure
8.3.2.1.1. Causal organism known
8.3.2.1.2. Causal organism unknown
8.3.2.2. With circulatory failure (aka Septic Shock)
8.3.2.2.1. Causal organism unknown
8.3.2.2.2. Causal organism known