Coding tips: How to code viral sepsis

Coding viral sepsis has been a challenge for coders and has triggered many questions in coding communities since 2016. The question has reemerged during ongoing pandemic with rise of COVID-19 virus infections. In some cases, COVID-19 virus infection became systemic and progressed to viral sepsis.

According to the American Hospital Association (AHA) Coding Clinic, “Viral sepsis is a systemic infection caused by the presence of a virus in the blood. Although sepsis is most commonly caused by bacterial infection, it may also be caused by virus, fungi, and/or parasites.”

Currently, “viral” is not a subentry under “sepsis” in the index search of ICD-10-CM code book. Although A41.89 (Other specified sepsis) is classified in the section Other bacterial diseases (A30-A49), this is the closest and best available option in the ICD-10 CM code book for viral sepsis.

Per coding guidelines I.C.1.b an additional code from chapter one is needed to identify the organism.

1. Infectious agents as the cause of diseases classified to other chapters

"Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the infection code. In these instances, it is necessary to use an additional code from Chapter 1 to identify the organism. A code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified to other chapters, B96, Other bacterial agents as the cause of diseases classified to other chapters, or B97, Viral agents as the cause of diseases classified to other chapters, is to be used as an additional code to identify the organism. An instructional note will be found at the infection code advising that an additional organism code is required."

When the virus responsible for causing sepsis is not documented, code B97.89 (Other viral agents as the cause of diseases classified elsewhere) should also be assigned to indicate that sepsis is due to a viral infection.

To put everything into perspective, here are some examples of viral sepsis, responsible virus and the corresponding ICD-10-CM codes:

• Viral Sepsis: A41.89 + B97.89 (Other viral agents as the cause of diseases classified elsewhere)
• Sepsis due to COVID-19 virus: A41.89 + U07.1 (COVID-19)
• Sepsis due to dengue fever: A41.89 + A90 (Dengue fever)
• Sepsis due to Lyme disease: A41.89 + A69.29 (Other conditions associated with Lyme disease)
• Sepsis due to West Nile virus: A41.89 + A92.39 (West Nile virus infection with other complications)

You can find additional viral sepsis related coding scenarios in the AHA Coding Clinic for ICD-9-CM and ICD-10-CM/PCS (references below).

Roxana Safari, CCS, BA is the product owner of ICD-10-CM outpatient and profee for computer-assisted coding content at 3M Health Information Systems.

Break down silos between professional and facility coding.

References:

• ICD-10-CM/PCS Coding Clinic, Third Quarter ICD-10 2016 Page: 8 Effective with discharges: September 23, 2016
• ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2021 Page: 33 Effective with discharges: January 1, 2021