In cases of severe sepsis with organ dysfunction, how many codes are needed?

In cases of severe sepsis with organ dysfunction, the coding guidelines specify the need for two codes. The first code is used to identify the underlying condition (sepsis), while the second code is designated for the organ dysfunction that has occurred as a result of the sepsis. This dual coding approach ensures that both the systemic infection and the effects it has on the body's functions are accurately documented.

Specifically, the first code captures the sepsis itself, and additional codes from the relevant chapter of the ICD-10-CM are utilized to describe the specific organ dysfunction, such as acute kidney failure, respiratory failure, or shock. This comprehensive coding reflects the complexity of the patient’s condition, allows for appropriate treatment planning, and improves data collection for research and statistics regarding sepsis and its complications.