Should we query an MD for SIRS if the patient presents with a viral infection (say viral syndrome) but meet the SIRS criteria? If yes, how is this coded?
• Yes, SIRS can result from an infection caused by any number of causes (i.e., bacteria, rickettsiae, fungi, viruses, protozoa and rheumatoidpolyarthtritis) as well as non-infectious causes. • If the term “viral syndrome” is documented and nothing more specific, we code 079.99, unspecified viral infection. • As for sequencing, this is dependent on a several issues. • Was the SIRS POA? • If yes, and no specific virus is identified, assign 079.99 viral syndrome, unspecified as your PDX because this is the systemic infection in this case. (Septicemia 038.X is used as a default code only when there is a no other stated systemic infection. “Septicemia, viral” is coded 079.99.) • Code also 995.9X as a secondary diagnosis along with code for any associated organ dysfunction if present. • If there was no associated organ dysfunction, assign code 995.91. • If there was organ dysfunction, assign code 995.92 and code all examples of associated organ dysfunction documented in the record. Rationale
