Tuesday, April 6, 2021

Coding Sepsis and Pneumonia

Coding for sepsis is challenging under any circumstances.  Throw in a pneumonia diagnosis and coding gets exponentially more complicated.  This In the kNOW edition looks at recent Coding Clinic guidance on proper coding for sepsis and pneumonia under several different scenarios.

In a second quarter 2020 update to Coding Clinic, a question was posed regarding the appropriate coding and sequencing for a patient who was admitted with sepsis due to aspiration pneumonia.  Clarification provided indicated that when the sepsis is related to the aspiration pneumonia (documentation states “due to” or “related”) then it is the sepsis that should be listed as the principal diagnosis.  However, coding professionals must also remember that while aspiration pneumonia can be caused by inhalation of material, such as food, it can also involve infection.  Therefore, because sepsis results from infection, sepsis due to aspiration pneumonia must also include an infectious pneumonia.  In order to capture all components of the diagnosis sepsis due to aspiration pneumonia, three codes are necessary:

            A41.9 Sepsis, unspecified organism

 J189 Pneumonia, unspecified organism 

            J69.0 Pneumonitis due to inhalation of food and vomit

A slightly different scenario asks the question, if the patient is admitted with sepsis due to aspiration pneumonia and the aspiration pneumonia is described as being secondary to a probable, gram-negative bacteria how should this be coded?  Again, coding professionals are reminded that if both the sepsis and aspiration pneumonia are present on admission, it is the sepsis that should be sequenced as the principal diagnosis in keeping with Official Coding Guideline I.C.1.d.4.  That guideline states:

            "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 first and the code for the localized infection should be assigned as a secondary diagnosis."

Again, multiple codes are required to accurately capture the complete diagnostic statement.  The codes that should be assigned are:

            A41.50 Gram-negative sepsis, unspecified

            J15.6 Pneumonia due to other Gram-negative bacteria

            J69.0 Pneumonitis due to inhalation of food and vomit

The final clarification in the second quarter 2020 Coding Clinic update addressed severe sepsis due to ventilator-associated pneumonia (VAP).  In this scenario, the VAP is further described as due to both Escherichia coli and methicillin susceptible Staphylococcus aureus.  Along with proper code assignment and sequencing, clarification was requested on whether the VAP should be considered a complication or a localized infection. 

The response from Coding Clinic was that the ventilator-associated pneumonia should be considered to be a localized infection.  Following our coding guideline referenced earlier, the sepsis code would then be assigned as the principal diagnosis.  In this case, since there are two different organisms noted as being responsible for the sepsis, either could be sequenced first.  The coding could look like this:

             A41.51 Sepsis due to Escherichia coli [E. coli]

             A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus (alternate PDx)

             J95.851 Ventilator associated pneumonia

             R65.20 Severe sepsis without septic shock

Hopefully, these clarifications from Coding Clinic will make it easier to code sepsis and pneumonia.

Now you are In the kNOW!!


About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.