ICD-9-CM Official Guidelines for Coding and Reporting - Office of ...

preclude querying the provider for clarification about
terms used in the documentation:
(i) Septicemia generally refers to a systemic
disease associated with the presence of
pathological microorganisms or toxins in the
blood, which can include bacteria, viruses, fungi
or other organisms.
(ii) Systemic inflammatory response syndrome
(SIRS) generally refers to the systemic response
to infection, trauma/burns, or other insult (such
as cancer) with symptoms including fever,
tachycardia, tachypnea, and leukocytosis.
(iii)Sepsis generally refers to SIRS due to infection.
(iv) Severe sepsis generally refers to sepsis with
associated acute organ dysfunction.
(b)
The Coding of SIRS, sepsis and severe sepsis
The coding of SIRS, sepsis and severe sepsis requires a
minimum of 2 codes: a code for the underlying cause
(such as infection or trauma) and a code from
subcategory 995.9 Systemic inflammatory response
syndrome (SIRS).
(i) The code for the underlying cause (such as
infection or trauma) must be sequenced before
the code from subcategory 995.9 Systemic
inflammatory response syndrome (SIRS).
(ii) Sepsis and severe sepsis require a code for the
systemic infection (038.xx, 112.5, etc.) and
either code 995.91, Sepsis, or 995.92, Severe
sepsis. If the causal organism is not
documented, assign code 038.9, Unspecified
septicemia.
(iii)Severe sepsis requires additional code(s) for the
associated acute organ dysfunction(s).
(iv) If a patient has sepsis with multiple organ
dysfunctions, follow the instructions for coding
severe sepsis.
ICD-9-CM Official Guidelines for Coding and Reporting
Effective October 1, 2008
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