How many codes are required for coding severe sepsis?

When coding for severe sepsis, it is necessary to use two codes. The first code is for the underlying infection, which captures the source of the sepsis, such as pneumonia, urinary tract infection, or an abdominal source. The second code is for the severe sepsis itself. According to the ICD-10-CM guidelines, when a patient has severe sepsis, it is essential to document both the sepsis and the specific infection to fully convey the clinical picture.

This coding guideline helps ensure proper documentation for the treatment provided and supports more accurate data collection and reimbursement. Each component is essential for a comprehensive medical record, making the use of two codes necessary to adequately reflect the condition being treated.