Tick-borne illness and Sepsis
Have a pt who was admitted in Septic Shock, found (after many tests done) to have RMSF (had history of tick bite and they pulled a tick off pt on admission). Also pt had: DIC, acute resp failure, hyponatremia, HLH due to RMSF, and few other diagnoses that are not cc/mcc.
My question is: what is the Pdx? Sepsis or the RMSF?
Coding guidelines for sepsis state:
Sepsis, Severe Sepsis, and Septic Shock
ICD-10-CM Official Guidelines for Coding and Reporting
(b) Severe sepsis
- The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign codeA41.9, Sepsis, unspecified organism, for the infection. Additional code(s) for the associated acute organ dysfunction are also required.
- Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes.
2) Septic shock
- (a) Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction.
- For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65.21,Severe sepsis with septic shock or code T81.12, Postprocedural septic shock. Any additional codes for the other acute organ dysfunctions should also be assigned. As noted in the sequencing instructions in the Tabular List, the code for septic shock cannot be assigned as a principal diagnosis.
Thanks (in advance) for any insight!