Sequenciação na codificação da sépsis com infeção localizada

"A sepsis já pode ser primeiro diagnóstico eu sei, mas quando se sabe o local de partida, não deverá ser este o primeiro diagnóstico?"
 

(Responde Fernando Lopes)

 
O índice alfabético não tem instruções de sequenciação para a codificação da sépsis.
Apenas obriga a não esquecer as disfunções orgânicas agudas relacionadas e o choque séptico, se mencionados:
 
Sepsis (generalized) (unspecified organism) A41.9
- with
- - organ dysfunction (acute) (multiple) R65.20
- - - with septic shock R65.21
 
Na lista tabular já aparecem algumas instruções de sequenciação: 
 
A40 Streptococcal sepsis 
Code first postprocedural streptococcal sepsis (T81.4-)
streptococcal sepsis during labor (O75.3)
streptococcal sepsis following abortion or ectopic or molar pregnancy (O03-O07, O08.0)
streptococcal sepsis following immunization (T88.0)
streptococcal sepsis following infusion, transfusion or therapeutic injection (T80.2-)
 
A41 Other sepsis 
Code first postprocedural sepsis (T81.4-)
sepsis during labor (O75.3)
sepsis following abortion, ectopic or molar pregnancy (O03-O07, O08.0)
sepsis following immunization (T88.0)
sepsis following infusion, transfusion or therapeutic injection (T80.2-)
 
Mas, não sendo uma situação de infeção pós-operatória, não é apresentada instrução para o local de partida da infeção.
No entanto, investigando a subcategoria T81.4- surgem algumas pistas:
 
T81.4 Infection following a procedure
Wound abscess following a procedure 
Use additional code to identify infection 
Use additional code (R65.2-) to identify severe sepsis, if applicable
 
Ou seja, a infeção é codificada como diagnóstico adicional nas situações de infeção (ou de sépsis) pós-operatória.
 
É aqui que entram as Guidelines: "a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction." (ICD-10-CM Official Guidelines for Coding and Reporting, FY 2018, Page 2 of 117)
 
(a) Sepsis
For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism. (ICD-10-CM Official Guidelines for Coding and Reporting, FY 2018, Page 21 of 117)
 
4) Sepsis and severe sepsis with a localized infection
If the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis. 
If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn’t develop until after admission, the localized infection should be assigned first, followed by the appropriate sepsis/severe sepsis codes. (ICD-10-CM Official Guidelines for Coding and Reporting, FY 2018, Page 24 of 117)
 
A resposta para esta questão está, pois, neste último parágrafo e permite codificar, por exemplo, um doente internado por pneumonia que apenas desenvolve sépsis durante o internamento:
J18.9   Pneumonia, unspecified organism (NB: PNA Sim)
A41.9  Sepsis, unspecified organism (NB: PNA Não)
 
De notar o seguinte:
- a "underlying systemic infection" (que aparece acima nas Guidelines e em vários locais da lista tabular) é a própria sépsis e a "localized infection" é a infeção do local;
- A subcategoria T81.4 é subdividida a partir de 1-10-2018:
 
T81.40 Infection following a procedure, unspecified 
T81.41 Infection following a procedure, superficial incisional surgical site
Subcutaneous abscess following a procedure
Stitch abscess following a procedure 
T81.42 Infection following a procedure, deep incisional surgical site
Intra-muscular abscess following a procedure 
T81.43 Infection following a procedure, organ and space surgical site
Intra-abdominal abscess following a procedure
Subphrenic abscess following a procedure 
T81.44 Sepsis following a procedure 
Use additional code to identify the sepsis 
T81.49 Infection following a procedure, other surgical site
 
 
Fernando Lopes