AHA Coding Clinic® for ICD-9 - 2005 Issue 2; Ask the Editor

Influenza, Pneumonia, Septic Shock and Multi-Organ Failure

A 91-year-old man was admitted to the hospital with acute influenza and altered mental status. His condition deteriorated after admission and he developed a clinical picture of septic shock, pneumonia and hypotension, which was followed by acute myocardial infarction (AMI) and acute renal failure (ARF). We are unsure if code 038.9, Unspecified septicemia, should be assigned along with code 995.92, Systemic inflammatory response syndrome due to infectious process with organ dysfunction, and code 785.52, Septic shock, for the septic shock with multi-organ failure, since the physician did not explicitly document severe sepsis. The advice published in Coding Clinic Fourth Quarter 2003, page 73, seems to imply that severe sepsis is presumed in a patient with septic shock and organ failure. How should this case be coded? ...

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