If a perinate is documented as having sepsis without documentation of congenital or acquired, the default is congenital, and a code from category P36 should be assigned.

Question

Quizplus · Accepted Answer

According to the ICD-10-CM Official Guidelines for Coding and Reporting, if sepsis is only documented in a perinate without any further specification, the default is to assume it is congenital and assign a code from category P36.

If a Perinate Is Documented as Having Sepsis Without Documentation