ICD-10-CM_PCS Preparing for ICD-10 Implementation课件.ppt

(b) Severe sepsis The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified, for the infection. Additional code(s) for the associated acute organ dysfunction are also required. Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes. 2) Septic shock Septic shock is circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction. For all cases of septic shock, the code for the underlying systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock. Any additional codes for the other acute organ dysfunctions should also be assigned. Septic shock indicates the presence of severe sepsis. Code R65.21, Severe sepsis with septic shock, must be assigned if septic shock is documented in the medical record, even if the term severe sepsis is not documented. * 6) Secondary Diabetes Mellitus Codes under categories E08, Diabetes mellitus due to underlying condition, and E09, Drug or chemical induced diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, or poisoning). (b) Assigning and sequencing secondary diabetes codes and its causes The sequencing of the secondary diabetes codes in relationship to codes for the cause of the diabetes is based on the Tabular List instructions for categories E08 and E09. For example, for category E08, Diabetes mellitus due to underlying condition, code first the underlying condition; for category E09, Drug or chemical induced diabetes mellitus, code first the drug or chemical (T36-T65).