Find comprehensive information on sepsis due to pneumonia, including clinical documentation tips, ICD-10 codes (J18.9, A48.9, R65.2), and best practices for healthcare professionals. Learn about severe sepsis, septic shock, pneumonia symptoms, diagnosis, treatment, and the importance of accurate medical coding for reimbursement. This resource provides guidance on documenting pneumonia as a cause of sepsis and understanding the clinical implications for patient care.
Also known as
Other bacterial diseases
Covers streptococcal sepsis, other specified bacterial sepsis.
Pneumonia
Encompasses various types of pneumonia like bacterial and viral.
Sepsis
Specifically indicates severe sepsis.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the pneumonia documented as the cause of sepsis?
Yes
Organ dysfunction documented?
No
Do NOT code sepsis. Code pneumonia only (J18.9). Query physician if sepsis suspected.
When to use each related code
| Description |
|---|
| Sepsis due to Pneumonia |
| Severe Sepsis |
| Pneumonia, unspecified organism |
Coding sepsis due to pneumonia without identifying the causative organism when documented leads to inaccurate severity and reimbursement.
Miscoding Systemic Inflammatory Response Syndrome (SIRS) as sepsis due to pneumonia can result in overcoding and compliance issues.
Failing to specify the type of pneumonia (e.g., bacterial, viral) when documented impacts coding accuracy and quality reporting.
Patient presents with symptoms consistent with sepsis secondary to pneumonia. The patient exhibits fever greater than 100.4 degrees Fahrenheit, heart rate exceeding 90 beats per minute, respiratory rate above 20 breaths per minute, and altered mental status. White blood cell count is elevated with a left shift. Blood cultures have been drawn and sent for analysis. Chest X-ray reveals infiltrates consistent with pneumonia. The patient reports productive cough with purulent sputum, shortness of breath, and pleuritic chest pain. Differential diagnoses included influenza, acute bronchitis, and COVID-19; however, clinical presentation and imaging findings support the diagnosis of pneumonia. The patient meets the Systemic Inflammatory Response Syndrome (SIRS) criteria and, in conjunction with suspected infection, fulfills the sepsis diagnostic criteria. Treatment initiated includes broad-spectrum intravenous antibiotics, fluid resuscitation, and supplemental oxygen. The patient is being closely monitored for signs of septic shock and organ dysfunction. Prognosis is guarded and dependent on response to therapy. ICD-10 code J18.9 for Pneumonia, unspecified organism and R65.21 for Severe sepsis are documented for billing and coding purposes. Further investigations may include arterial blood gas analysis and repeat chest imaging. Patient education provided regarding pneumonia symptoms, sepsis management, and the importance of adhering to the prescribed antibiotic regimen. The patient's condition will be reassessed regularly and treatment adjusted as indicated.