If a patient has sepsis and associated acute organ dysfunction, which term is used for coding?

The correct term for coding when a patient has sepsis along with acute organ dysfunction is "severe sepsis." This classification is important in the context of ICD-10-CM because it specifically denotes not only the presence of sepsis but also the additional clinical concern of organ dysfunction, which indicates a more serious health condition.

Severe sepsis is characterized by the body's systemic response to infection leading to organ failure or dysfunction, which significantly affects treatment protocols and patient management. It aligns with definitions found in clinical guidelines, emphasizing that any type of organ failure associated with sepsis escalates the severity of the condition and requires more intensive therapeutic interventions.

Understanding the distinction between severe sepsis and other variations like acute or chronic is essential for accurate coding and effective patient care. Acute sepsis, while it implies a recent onset, does not include the critical aspect of organ dysfunction. Chronic sepsis is generally not a recognized term in ICD-10 coding, and complex sepsis lacks the precise definition needed for correct coding. Thus, recognizing severe sepsis allows coding professionals to capture the full clinical picture for appropriate care and reimbursement.