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

clear as to whether an acute organ dysfunction is related to the
sepsis or another medical condition, query the provider.
6) Septic shock
(a)
Sequencing of septic shock
Septic shock generally refers to circulatory failure
associated with severe sepsis, and, therefore, it
represents a type of acute organ dysfunction.
For all cases of septic shock, the code for the systemic
infection should be sequenced first, followed by codes
995.92 and 785.52. Any additional codes for 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.
(b)
Septic Shock without documentation of severe sepsis
Septic shock indicates the presence of severe sepsis.
Code 995.92, Severe sepsis, must be assigned with code
785.52, Septic shock, even if the term severe sepsis is
not documented in the record. The “use additional
code” note and the “code first” note in the tabular
support this guideline.
7) Sepsis and septic shock complicating abortion and
pregnancy
Sepsis and septic shock complicating abortion, ectopic
pregnancy, and molar pregnancy are classified to category
codes in Chapter 11 (630-639).
See section I.C.11.
8) Negative or inconclusive blood cultures
Negative or inconclusive blood cultures do not preclude a
diagnosis of septicemia or sepsis in patients with clinical
evidence of the condition, however, the provider should be
queried.
9) Newborn sepsis
See Section I.C.15.j for information on the coding of newborn
sepsis.
ICD-9-CM Official Guidelines for Coding and Reporting
Effective October 1, 2008
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