Coding Sepsis vs. Septic Shock

By Melanie Endicott

The definitions and clinical criteria of sepsis and septic shock have been revised, per an article published February 23, 2016 in the Journal of the American Medical Association (JAMA). The recommendations from the 19 physician members of the task force that wrote the new definitions were:

  • “Sepsis should be defined as a life-threatening organ dysfunction caused by dysregulated host response to infection.”
  • “Septic shock should be defined as a subset of sepsis in which particularly proud circulator, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.”

The table below shows the new clinical criteria:

Sepsis (ICD-10-CM code R65.20 Septic Shock (ICD-10-CM code R65.21
  • Suspected or documented infection
  • An acute increase of ≥ 2 SOFA points1
  • Sepsis
  • Vasopressor therapy needed to elevate MAP2 ≥ 65 mm Hg
  • Lactate > 2 mmol/L (18 mg/dL) despite adequate fluid resuscitation
1SOFA — Sequential (Sepsis-related) Organ Failure Assessment
2MAP — mean arterial pressure

What does this change mean for the coding professional? Coders still need to be assigning codes based on physician documentation. What might change is the clinical validation portion of sepsis and septic shock by both CDI and coding professionals. Facilities may need to adopt (or revise existing) internal policies on how to consistently and compliantly code sepsis and septic shock based on these new definitions.

How is your facility dealing with this definition and clinical criteria change? Has this impacted your coding or CDI staff at all?

Read the article “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” published in JAMA here.

Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, is senior director of HIM practice excellence, coding and CDI products development at AHIMA. She has over 15 years experience in HIM and coding, with her most recent focus being in ICD-10-CM/PCS, and has presented numerous times at the regional, state, and national levels on HIM and coding topics. She was previously a director of HIM practice excellence, focusing on coding products, resources, and education, at AHIMA. Melanie is an AHIMA-approved ICD-10-CM/PCS trainer and an ICD-10 Ambassador.

Original source:
Endicott, Melanie. "Coding Sepsis vs. Septic Shock" (Journal of AHIMA website), April 2016.