Sepsis

A few important facts to know. 

Bacteremia 

Bacteremia is under signs and symptoms. Actually it is only a lab findings. So all by itself, it means nothing and does not mean that patient is septic or not.

Septicemia

There is only a single reference to septicemia in ICD-10-CM, and this can be found classified under the code for sepsis, unspecified organism. Otherwise, it's almost as if it does not exist. I know that clinically we sometimes use the word "septicemia" to say sepsis with bacteremia but this does not translate into coding so avoid it. 

SIRS
 

The only references to SIRS in the ICD-10-CM Official Guidelines for Coding and Reporting are those specifically related to SIRS due to a non-infectious process. Which means that SIRS resulting from infection will not be coded as such!

Sepsis

In the ICD-10-CM world, in order to accurately reflect the severity of illness and risk of mortality for patients who present with a localized infection, SIRS, and a clinical picture of sepsis, the physician must document sepsis as a diagnosis. A localized infection with clinical documentation of SIRS only can be coded and reported as the localized infection. I will repeat this phrase : 

A localized infection with clinical documentation of SIRS only can be coded and reported as the localized infection! So if sepsis is there - document it!

Document the underlying local infection and specify the causal relationship to a local infection and/or procedure. 

Also, it's important to identify the causative organism

Ex:  

• Staphylococcus:

• MSSA

• MRSA

• Streptococcus:

• Group A

• Group B

• Pneumoniae

• Other gram negative:

• Anaerobes

Include any associated organ dysfunction or failure such as

• Severe sepsis

• Septic shock

The term "urosepsis" cannot be coded! so I never use it.