For a diagnosis of sepsis, what must be assigned?

In the case of sepsis, assigning a code for the underlying systemic infection is essential because it captures the root cause of the condition. Sepsis is a complex response by the body to an infection that can lead to organ dysfunction and other serious complications. By coding for the underlying infection, health care providers can accurately reflect the nature of the patient's condition, ensure appropriate treatment plans, and provide accurate data for health statistics and epidemiology.

While codes for sequela, acute organ dysfunction, or symptoms may relate to a patient's overall condition, they do not sufficiently represent the primary reason for sepsis. The goal of coding in this context is to identify and document the source of infection accurately, as this informs clinical management and interventions that may need to be undertaken to address the infection and prevent further complications. Therefore, focusing on the underlying systemic infection aligns with the criteria that aim for clarity and specificity in medical coding for sepsis.