A 68-year-old male presents to our facility with symptoms of malaise, fatigue and fever. The patient was diagnosed with systemic inflammatory response syndrome (SIRS). However, he did not have sepsis. The provider listed “SIRS secondary to pneumonia,” in his diagnostic statement. My particular encoder is directing me to the sepsis code. ICD-10-CM does not seem to have a code for SIRS due to infectious process. How should we report SIRS due to pneumonia?
Assign only code J18.9, Pneumonia unspecified organism. When sepsis is not present, no other code is required. The ICD-10-CM does not provide a separate code or index entry for SIRS due to an infectious process. If the health record documentation appears to meet the criteria for sepsis, the provider should be queried for clarification. Encoders are tools that may assist coders; however the codes must be validated and supported by the health record documentation.