ACDIS
ICD-10 Fact Sheet – Bacteremia/Sepsis/Severe Sepsis/Septic Shock
This month’s Clinical Documentation Improvement tips section will focus on documenting Bacteremia/Sepsis/Severe Sepsis/Septic Shock in ICD-10. To ensure that Quality Metrics, Risk of Mortality, and complexity of care rendered by the physician and the facility are accurately reported, please consider the following information.
The following are not synonymous terms: bacteremia, sepsis, severe sepsis, and septic shock. Please clearly document the most appropriate term in a consistent manner to ensure accurate reporting.
Bacteremia
Note that bacteremia is coded as an abnormal laboratory finding and that this term is not reported as septicemia or sepsis.
Urosepsis
The term “Urosepsis” DOES NOT EXIST IN ICD-10 and cannot be coded - this term will result in a query for documentation clarification regarding diagnosis, underlying cause, etc. (i.e. UTI, Sepsis, or other condition).
The following definitions are offered:
Definitions:
• Bacteremia – Presence of viable bacteria in the blood.2
• Sepsis – Sepsis is defined as the presence (probable or documented) of infection together with systemic manifestations of infection. Two or more of the following: Body temperature >38 ◦C or 90 beats/min; Respiratory rate >20 breaths/min or hyperventilation with a PaCO2 less than 32 mmHg; White blood cell count >12000/mm3, 10% immature neutrophils.2
• Severe Sepsis – acute organ dysfunction or tissue hypoperfusion secondary to infection1
• Septic Shock – severe sepsis plus hypotension not reversed with adequate fluid resuscitation or blood lactate >4 mmol/L.1
• Hypotension – sepsis-induced hypotension defined as a systolic blood pressure (SBP) ................
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