Sepsis and Respiratory Failure: Sequencing the Principal Diagnosis Correctly

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Sepsis and Respiratory Failure: Sequencing the Principal Diagnosis Correctly

By SZ Ahmed CCS

Sepsis frequently coexists with organ dysfunction, such as acute respiratory failure, creating complexity for coding professionals tasked with selecting the principal diagnosis (PDX). According to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) guidelines, when both conditions are present on admission (POA) and treated, sepsis should be sequenced as the PDX if it is the underlying cause of the organ dysfunction. This article examines this guideline, offering practical examples to guide accurate coding and ensure proper Diagnosis-Related Group (DRG) assignments.

Understanding Sepsis as the Driver

When a patient presents with sepsis and respiratory failure, coders must determine the causal relationship. The ICD-10-CM Official Guidelines (Section I.C.1.d) state that if sepsis and acute organ dysfunction are both POA, and no other cause (e.g., trauma or pulmonary embolism) is documented for the dysfunction, sepsis is sequenced as the PDX, with respiratory failure as a secondary diagnosis (SDX). This reflects sepsis as the systemic condition often triggering organ failure.


Coders need to look for documentation linking respiratory failure to sepsis,” says Jane Smith, CPC, a coding consultant. “Terms like ‘due to sepsis’ or ‘secondary to infection’ signal that sepsis should lead the sequence.”


Real-World Applications

Coding errors highlight the importance of this guideline. In one case, a patient was admitted with septic shock and respiratory failure, but respiratory failure was initially coded as the PDX. Documentation confirmed septic shock—a severe form of sepsis that often includes organ dysfunction—as the admitting condition. Correctly, the PDX was revised to sepsis (A41.9, Sepsis, unspecified organism) with septic shock (R65.21) and respiratory failure (J96.01, Acute respiratory failure with hypoxia) as SDXs, yielding DRG 871 (Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours with Major Complication or Comorbidity). “Septic shock inherently involves organ dysfunction, making sepsis the PDX,” Smith notes.


Another error involved a coder selecting respiratory failure (J96.01) as the PDX because it appeared first on the problem list, despite ED notes stating, “Admit for sepsis secondary to pneumonia with acute hypoxic respiratory failure.” This led to an incorrect DRG 208 (Respiratory System Diagnoses with MCC), risking audit scrutiny and financial loss. Correct coding assigned A41.9 (Sepsis) as the PDX, with J96.01 (Respiratory failure) and J18.9 (Pneumonia) as SDXs, aligning with DRG 871.


Practical Scenarios

Consider a 78-year-old male presenting with fever, chills, shortness of breath, and altered mental status. The ED documents, “Admit for sepsis secondary to pneumonia with acute hypoxic respiratory failure.” Treatment includes IV antibiotics and oxygen support. Coding correctly assigns A41.9 (Sepsis) as the PDX, with J96.01 (Respiratory failure) and J18.9 (Pneumonia) as SDXs, resulting in DRG 871. This reflects sepsis as the root cause of admission and respiratory failure as a complication.


Conversely, if respiratory failure is attributed to a condition like chronic obstructive pulmonary disease (COPD) exacerbation, documented independently of sepsis, the coding sequence changes. For example, if ED notes indicate respiratory failure due to COPD with sepsis noted later, J44.1 (COPD with acute exacerbation) may be the PDX, with A41.9 (Sepsis) as an SDX, adjusting the DRG accordingly.


Best Practices for Coders

Accurate sequencing requires careful review of ED notes, history and physical, and progress notes for causal language linking sepsis to organ dysfunction. “Coders should ask, ‘Which condition drove the admission?’” advises Michael Lee, RHIA, a compliance officer. “If sepsis sparked the respiratory failure, it’s the PDX.” Red flags include respiratory failure listed first without justification or lack of linking terms like “due to sepsis.” Collaboration with providers to clarify relationships ensures defensible coding.


By mastering this guideline, coders can avoid DRG errors, support compliance, and optimize reimbursement in complex sepsis cases.


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