AHA Coding Clinic® for ICD-9 - 1988 First Quarter
Septicemia and Septic Shock
Note: This information has been superceded by Coding Clinic, Fourth Quarter 2003 pages 79-81. The combination of general sepsis (septicemia) and shock resulting from injured and infected tissue was recognized as a clinical condition before the germ theory of disease was well understood. Although a great deal is now known about the basic pathophysiology of the condition, the diagnosis is still based largely on the history and physical findings of the patient (clinical evidence). This condition is extremely serious and has a high mortality rate. The metabolic and circulatory compromise and collapse in septicemia are caused by the effects...
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Article Overview
This article reviews coding-oriented discussion of septicemia and septic shock, including how these conditions are documented, the role of blood culture results, and when clarification may be needed for imprecise terms such as site-specific sepsis. It is relevant to medical coders and billing professionals working with infection-related diagnoses and pregnancy-related classification references. The article also notes that the material has been superseded by a later Coding Clinic reference.
Why This Topic Matters
Accurate documentation and classification of septicemia and septic shock can affect code selection and problem list sequencing. The article highlights situations where diagnosis wording may be ambiguous and where additional clarification may be necessary for proper coding.
Article Sections
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Note
A supersession notice indicating that the information has been replaced by a later Coding Clinic reference.
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Clinical discussion of septicemia and septic shock
Background discussion of the condition, its general clinical context, and the significance of documentation in coding.
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Blood culture and diagnostic considerations
Discussion of laboratory testing, negative culture results, and why clinical evidence may still support the diagnosis.
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Coding sequencing and related classification references
General coding guidance on how the diagnoses are documented and references to classification groupings in other chapters.
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Clarification of imprecise sepsis terminology
Discussion of ambiguous wording such as site-specific sepsis terminology and the need for clarification when the intent is not clear.
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Urosepsis
A short discussion of how the term is indexed and why additional provider clarification may be needed in some cases.
What You Will Learn
- How the article frames septicemia and septic shock from a coding perspective
- Why laboratory findings may not be sufficient by themselves to resolve the diagnosis
- When documentation may be considered imprecise and require clarification
- What general classification references are mentioned in connection with related conditions
Who Should Read This
- Medical coders
- Coding auditors
- Revenue cycle staff
- Compliance professionals
- Clinical documentation specialists
Codes Discussed
Code Ranges Discussed
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