AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2019 Issue 2; Ask The Editor

Systemic Inflammatory Response Syndrome without Underlying Cause

A patient with fever and leukocytosis is admitted to the hospital for workup to rule out infection. No clear source of the symptoms was found, and the patient was diagnosed with SIRS as the discharge diagnosis. What is the appropriate principal diagnosis when a patient presents with SIRS and no underlying cause is found, SIRS (R65.10) or the symptoms, e.g., fever, leukocytosis, etc.? There is a “code first” note at category R65.1, Systemic inflammatory response syndrome (SIRS) of non-infectious origin, which states to “code first underlying condition.” ...

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