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

(v) Either the term sepsis or SIRS must be
documented to assign a code from subcategory
995.9.
(vi) See Section I.C.17.g), Injury and poisoning, for
information regarding systemic inflammatory
response syndrome (SIRS) due to trauma/burns
and other non-infectious processes.
(c)
Due to the complex nature of sepsis and severe sepsis,
some cases may require querying the provider prior to
assignment of the codes.
2) Sequencing sepsis and severe sepsis
(a)
Sepsis and severe sepsis as principal diagnosis
If sepsis or severe sepsis is present on admission, and
meets the definition of principal diagnosis, the systemic
infection code (e.g., 038.xx, 112.5, etc) should be
assigned as the principal diagnosis, followed by code
995.91, Sepsis, or 995.92, Severe sepsis, as required by
the sequencing rules in the Tabular List. Codes from
subcategory 995.9 can never be assigned as a principal
diagnosis. A code should also be assigned for any
localized infection, if present.
If the sepsis or severe sepsis is due to a postprocedural
infection, see Section I.C.1.b.10 for guidelines related
to sepsis due to postprocedural infection.
(b)
(c)
Sepsis and severe sepsis as secondary diagnoses
When sepsis or severe sepsis develops during the
encounter (it was not present on admission), the
systemic infection code and code 995.91 or 995.92
should be assigned as secondary diagnoses.
Documentation unclear as to whether sepsis or
severe sepsis is present on admission
Sepsis or severe sepsis may be present on admission but
the diagnosis may not be confirmed until sometime
after admission. If the documentation is not clear
whether the sepsis or severe sepsis was present on
admission, the provider should be queried.
ICD-9-CM Official Guidelines for Coding and Reporting
Effective October 1, 2008
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