Q&A: Coding mixed cardiogenic and septic shock

Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?

A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed below there is an Excludes1 note. Remember, Excludes 1 notes instruct us that we cannot use codes from this grouping with those listed within the Excludes 1 note. Cardiogenic shock (R57.2) falls within this grouping. Also listed is R65.2 septic shock. Purely relying on the coding conventions, I would conclude that we cannot code septic shock with cardiogenic shock. See the image below.

R37 Shock, not elsewhere classified

But, there is more to consider. AHA Coding Clinic-for ICD-10-CM/PCS, Fourth Quarter, 2015.

“There are circumstances that have been identified where some conditions included in Excludes 1 notes should be coded, and thus might be more appropriate for an Excludes 2 note.

The new guidelines concerning Excludes 1 notes is intended to allow conditions to be reported together when appropriate even though they may currently be subject to an Excludes 1 note.”

So, does the situation you describe allow for us to code both types of shock? To adequately answer this, we would need to delve into the record a bit deeper. To override the Excludes 1 note, the documentation would need to explicitly state there was both an infectious cause of hypoperfusion at the chemical/cellular level AND a mechanical pump failure causing reduced hemodynamic performance (but it doesn’t have to be in those exact words as long as the evidence is within the record and the doctor provided both diagnoses). You do have the statement from the provider that the shock was of multiple etiologies and this is supportive of reporting both codes. I would like to see treatment protocols that support the treatment of both etiologies documented in the record as well.

This would be a great discussion for you to investigate with your coding team to ensure you are providing them the appropriate documentation to capture the severity of the patient’s conditions.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.