ICD-10-CM Official Coding Guidelines for Coding and Reporting direct us that “if severe sepsis is present on admission and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List.” We are further directed that, “if the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List.” I believe that there are very few absolutes in coding, and the sepsis guidelines are a good example of this. However, my answer to this question is no, not always. Is sepsis always sequenced as the principal diagnosis when it is present on admission? Some may say yes, because after all, that’s what is stated in the official coding guidelines. I would like to challenge readers to periodically review and re-review the guidelines in an effort to gain complete understanding of all aspects of sepsis coding, and consider the following sepsis coding scenarios. Many times the more subtle details in the sepsis guidelines are overlooked, and sometimes they are not noticed at all.
When reviewing sepsis claims, all too often the primary focus is on searching provider documentation for signs and symptoms and/or clinical indicators that support the diagnosis of sepsis, or that support a query regarding the presence of sepsis.
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