RE: [EXTERNAL] RE: Flu with pneumonia, with Sepsis

I agree with Robert. (Code set 038.XX is used to report BACTERIAL Sepsis). The term Sepsis 'defaults' to a bacterial sepsis.


• The statement septicemia is coded to Unspecified Septicemia (038.9) if the type of septicemia/sepsis is not more specifically noted. Note the Description found in the Tabular List as follows: OTHER BACTERIAL DISEASES (030-041) Most sepsis/septicemia is classified to category 038, with fourth & fifth digits indicating the responsible organism.

 ICD provides specific 4th & 5th in the 038 Category found in the Tabular List to report specific bacteria causing sepsis/septicemia, for instance, 038.3, is used to report Septicemia Due to Anaerobes.

 Also note the “Exclusion Note” in the Tabular List at Category 038.8, Other Specified Septicemia, which directs one to alternative code selections when the septicemia/sepsis is not bacterial. Other types of sepsis/septicemia are classified to another organism, such as septicemia due to:

Anthrax (022.3)
Gonococcal (098.89)
Viral (079.99)
Plague (020.2)

 Also see the reference in the Index to Diseases for “septicemia, postoperative” – 998.59.

 An additional code is used with the code for septicemia/sepsis for any accompanying SIRS.

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

evanspx@sutterhealth.org
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