2025 ICD-10-CM code T81.44
(Active) Effective Date: N/A Revision Date: N/A Injury, poisoning and certain other consequences of external causes - T81.4 19 Feed
Sepsis following a procedure.
Medical necessity for the treatment of sepsis is established by the presence of signs and symptoms consistent with a systemic inflammatory response to infection, such as fever, elevated heart rate, elevated respiratory rate, and abnormal white blood cell count.The severity of the sepsis and the presence of organ dysfunction will further determine the intensity of care required.
The physician is responsible for documenting the cause-and-effect relationship between the procedure and the subsequent sepsis.This includes identifying the source of infection, the affected organs, and the severity of the sepsis.Additional codes should be used to specify the type of sepsis and any associated organ dysfunction.
- 19
- Injury, poisoning and certain other consequences of external causes (T07-T88)Complications of surgical and medical care, not elsewhere classified (T80-T88)
In simple words: This code represents sepsis, a serious body-wide inflammatory response to infection, which has occurred as a complication after a medical procedure.
Sepsis following a procedure. Use additional code to identify the sepsis.
Example 1: A patient undergoes a laparoscopic appendectomy and develops sepsis due to a post-surgical infection at the incision site. The physician documents the connection between the surgery and the sepsis., A patient receiving chemotherapy through a central venous catheter develops sepsis due to a catheter-related bloodstream infection. The physician notes the relationship between the catheter placement and the subsequent sepsis., A patient undergoes a colonoscopy and develops sepsis due to a perforation during the procedure. The physician documents the perforation and the resulting sepsis.
Documentation should clearly establish the cause-and-effect relationship between the procedure and the sepsis.This includes the type of procedure performed, the date of the procedure, the onset of sepsis symptoms, the suspected source of infection, and any associated organ dysfunction.Positive blood cultures or other diagnostic tests supporting the diagnosis of sepsis should also be documented.
** For accurate and comprehensive coding, it is essential to consult the complete ICD-10-CM Official Guidelines for Coding and Reporting.
- Specialties:Infectious Disease, Critical Care, General Surgery, and any specialty performing procedures.
- Place of Service:Inpatient Hospital, Emergency Room - Hospital