Crash Course: Compare ICD-10-CM 2019 Official Guidelines for Post-Op Sepsis to 2018 Rules

The ICD-10-CM 2019 Official Guidelines are out and offer more details on how to use new codes for sepsis following a procedure. Take a look at what’s new and get a handle on how to sequence these codes.

Remember These New Codes to Improve Sepsis Coding

ICD-10-CM 2019 includes these two new codes with instructional notes:

  • Obstetrical: O86.04 (Sepsis following an obstetrical procedure)
    • Use additional code to identify the sepsis
  • Other procedures: T81.44X- (Sepsis following a procedure)
    • Use additional code to identify the sepsis.

These codes are part of an expansion of O86.0 and T81.4– to allow more specificity in reporting the infection site, such as superficial, deep, or organ/space. You can read more about those codes in the blog post on surgical wound infection ICD-10-CM 2019 updates.

Get Help on Reporting Rules Beyond the Code Set

Sepsis can be challenging to code because of the sequencing involved. The notes with the new codes say to “use additional code.” The new Official Guidelines, effective on Oct. 1, 2018 (the same effective date as the ICD-10-CM 2019 codes), offers a little more guidance.

The updated sepsis guidelines are in section I.C.1.d.5.b and section I.C.1.d.5.c, starting on page 26 of the PDF.

Watch for the Phrase ‘If Known’ for Infection Site Rule

Let’s start with I.C.1.d.5.b (Sepsis due to a postprocedural infection). In the portion relevant to the new codes, the 2019 guidelines state:

For infections following a procedure, a code from T81.40, to T81.43 Infection following a procedure, or a code from O86.00 to O86.03, Infection of obstetric surgical wound, that identifies the site of the infection should be coded first, if known. Assign an additional code for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04). Use an additional code to identify the infectious agent. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.

What’s new? The changes mostly replace 2018 code options with 2019 options. But there’s also this helpful change:

  • 2018: The 2018 guidelines state you should report an infection code, such as T81.4- or O86.0, first, followed by the code for the specific infection.
  • 2019: The 2019 guidelines offer leeway for the realities of coding from documentation, clarifying that you should report a code from T81.40- to T81.43- or O86.00 to O86.03 first to identify the infection site “if known.” You also get more specific instructions that you should report the sepsis using T81.44- or O86.04, and that reporting an additional code for the infectious agent is also appropriate.

What’s the same? Continue to report a code from R65.2- for severe sepsis along with additional cods for acute organ dysfunction.

Tip: This isn’t everything in I.C.1.d.5.b. There’s also information on coding for infections following other services. If you code sepsis, reviewing the entire sepsis section of the guidelines is a good idea.

Leave R65.21 Off of These Claims

Now let’s move to the changes to I.C.1.d.5.c (Postprocedural infection and postprocedural septic shock).

Here is the wording in 2019:

If a postprocedural infection has resulted in postprocedural septic shock, assign the codes indicated above for sepsis due to a postprocedural infection, followed by code T81.12-, Postprocedural septic shock. Do not assign code R65.21, Severe sepsis with septic shock. Additional code(s) should be assigned for any acute organ dysfunction.

What’s new? The paragraph shown above from the 2019 guidelines doesn’t change much from a similar 2018 paragraph, but the 2019 version adds the rule to NOT assign R65.21 (Severe sepsis with septic shock) and adds the additional code note for acute organ dysfunction. Another changes is that the 2019 guidelines do NOT include a paragraph that was in the 2018 guidelines about post-op infection resulting in severe sepsis, and using T81.4- or O86.0 first followed by R65.20 (Severe sepsis without septic shock).

What About You?

Do you have any tips to help simplify coding for sepsis? What changes would you like to see to the Official Guidelines?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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