Are You Losing Revenue in Sepsis Coding? Try This DRG Simulator for Sepsis Coding and Decision Tool

ICD-10-CM · IPDRG Reference

Sepsis Coding & DRG Tool

Decision wizard · ICD-10 codes · DRG 870–872 / 853–855 simulator · Quiz · Error training

Sepsis coding & DRG decision wizard

Step-by-step guided workflow

1

Infection check

Sepsis requires documented or suspected infection

Is there documented or suspected infection?

!

Sepsis cannot be assigned. No infection documented. Review chart before proceeding.

2

SIRS clinical indicators

Select all indicators present in the chart

Clinical indicators (select all that apply)

Abnormal temperature

>38.3°C or <36°C

Heart rate >90 bpm

Tachycardia at rest

Respiratory rate >20/min

Or PaCO2 <32 mmHg

Abnormal WBC

>12K or <4K or >10% bands

Hypotension

SBP <90 or MAP <70

Altered mental status

Acute confusion or unresponsiveness

Elevated lactic acid

>2 mmol/L (severe: >4 mmol/L)

Positive blood culture

Bacteremia confirmed

0

No indicators selected

Select at least 2 to continue

3

Provider documentation

Only physician-documented diagnoses are codeable

Is sepsis documented by the provider?

4

Severity & organ dysfunction

Determines severity level and additional codes

Select severity level

Organ dysfunction (select all present)

Acute respiratory failure

J96.01 — MCC level

Acute kidney injury (AKI)

N17.9 — MCC level

Septic encephalopathy

G93.41 — MCC level

DIC

D65 — MCC level

Hepatic failure

K72.00 — MCC level

5

CC / MCC level

Determines DRG tier — not shown in code output

Highest complication level present

6

Procedure impact

Major OR procedure shifts DRG group entirely

Was a major OR procedure performed?

Common qualifying OR procedures

Excisional debridement

Bowel resection

Exploratory laparotomy

Drainage of deep abscess

Amputation

Joint replacement surgery

Final diagnosis

ICD-10-CM codes

Confidence level

DRG result

Assigned DRG

Medical DRGs (no OR procedure)

Surgical DRGs (with OR procedure)

i

Error detection

Auto-generated physician query

DRG assignment is simplified for learning. Actual grouping depends on full claim data, payer logic, ventilation hours, and complete code set. Always verify with official grouper software.

SIRS clinical indicators checker

Select all indicators present in the chart. 2+ = SIRS criteria met. Physician must document sepsis — lab values alone are not sufficient to code.

0

No indicators selected

Check applicable indicators above.

Severity classifier

Sepsis

Life-threatening organ dysfunction caused by dysregulated host response to infection. Must be documented by physician.

Severe sepsis

Sepsis + at least one acute organ dysfunction (renal failure, respiratory failure, encephalopathy, DIC).

Septic shock

Severe sepsis + persistent hypotension despite adequate fluid resuscitation. Always code R65.21.

SIRS (non-infectious)

Same criteria but without infection — trauma, burns, cancer. Do NOT code SIRS separately when infection is present.

ICD-10-CM sepsis code reference

Sepsis as principal diagnosis

Scenario A — admitted with sepsis + localized infection (both POA)

Patient admitted with staphylococcal sepsis due to pneumonia.

PDxA41.2Sepsis due to unspecified staphylococcus

SDxJ18.9Pneumonia, unspecified organism

Scenario B — septic shock with acute respiratory failure

Septic shock due to Group A Strep with aspiration pneumonia.

PDxA40.0Sepsis due to streptococcus, group A

SDxR65.21Severe sepsis with septic shock

SDxJ96.00Acute respiratory failure, unspecified

SDxJ69.0Pneumonitis due to inhalation of food/vomit

Scenario C — E. coli severe sepsis due to peritonitis with AKI

PDxA41.51Sepsis due to E. coli

SDxK65.9Peritonitis, unspecified

SDxR65.20Severe sepsis without septic shock

SDxN17.9Acute kidney failure, unspecified

Sepsis as secondary diagnosis

Scenario D — admitted for pneumonia, sepsis develops on day 5

PDxJ18.9Pneumonia, unspecified organism

SDxA41.2Sepsis due to unspecified staphylococcus

Scenario E — post-CABG MRSA wound infection → septic shock

PDxT81.44XASepsis following a procedure

SDxT81.42XAInfection following procedure, deep incisional

SDxA41.02Sepsis due to MRSA

SDxR65.21Severe sepsis with septic shock

SDxJ96.00Acute respiratory failure

Sepsis as PDx — scenario finder

All scenarios Sepsis IS PDx Sepsis is NOT PDx

PDx selection hierarchy

1

Final provider documentationFinal physician statement overrides all prior notes, CDI opinion, and lab values.

2

Query responseIf provider answers a query, that response is binding — even if the query was poorly worded.

!

CDI opinion is NOT primary evidenceCDI disagreement does not make a diagnosis codeable. Only physician documentation counts.

!

Only one PDx allowed"Both conditions treated" does NOT mean both can be PDx. Always select ONE.

Common / coder errors — audit training

Quiz

Score

0 / 0

0 of 0 answered

MS-DRG reference

MS-DRG	Category	Description
870	Medical	Septicemia or severe sepsis with MV >96 hrs
871	Medical	Septicemia or severe sepsis w/o MV >96 hrs — with MCC
872	Medical	Septicemia or severe sepsis w/o MV >96 hrs — without MCC
853	Surgical	Infectious & parasitic diseases with OR procedure — with MCC
854	Surgical	Infectious & parasitic diseases with OR procedure — with CC
855	Surgical	Infectious & parasitic diseases with OR procedure — without CC/MCC
698	Medical	Device-related infection / CAUTI
208	Medical	Respiratory failure / arrest with MCC
64	Medical	Intracranial hemorrhage or cerebral infarction with MCC
193	Medical	Simple pneumonia / pleurisy with MCC
862	Medical	Postoperative & post-traumatic infections with MCC
917	Medical	Poisoning & toxic effects of drugs with MCC
840	Medical	Lymphoma & non-acute leukemia with MCC
951	Medical	Other factors influencing health status (Hospice)
100	Medical	Seizures with MCC

Key definitions

Septicemia

Systemic disease associated with pathological microorganisms or toxins in blood.

SIRS

Systemic inflammatory response of non-infectious origin — trauma, burns, cancer.

Sepsis

Life-threatening organ dysfunction caused by a dysregulated host response to infection.

Severe sepsis

Sepsis with associated acute organ dysfunction.

Septic shock

Sepsis-induced circulatory failure with persistent hypotension despite adequate fluids.

POA

Present on admission — determines if complication occurred before or during hospitalization.

CAUTI

Catheter-associated UTI. Coded T83.511A — takes PDx priority over sepsis when device confirmed.

HAC program

Hospital-Acquired Condition Reduction Program. Postoperative sepsis included in Patient Safety Indicators.

Critical coding tips

!

R65.2x — never principal diagnosisCodes from subcategory R65.2 (Severe Sepsis) can NEVER be assigned as a principal diagnosis.

!

Urosepsis — not codeable"Urosepsis" has no ICD-10-CM code. Query provider for specific underlying infection.

!

Lab values alone ≠ sepsisSepsis cannot be assumed from labs alone. Physician must document it explicitly.

!

Septic shock always requires R65.21Must assign R65.21 even if "severe sepsis" is not documented separately.

i

Septic shock = minimum 3 codesUnderlying infection + R65.21 + codes for all associated acute organ dysfunction.

i

POA status drives sequencingSepsis POA → can be PDx. Sepsis after admission → SDx only. When unclear → query provider.

ICD-10-CM Sepsis Coding & DRG Tool · Based on OCG I.C.1.d · For educational use only. Always verify with current AHA Coding Clinic and official guidelines.