If sepsis is documented with septic shock, how should it be coded?

• A. Code septic shock as the primary diagnosis and omit sepsis.
• B. Sepsis may be coded separately from septic shock with appropriate sequencing; ensure the most severe condition is listed first.
• C. Only septic shock is coded when septic shock is documented.
• D. Sepsis is never coded if septic shock is documented.

Answer: (B)

When septic shock is documented along with sepsis, you should capture both conditions and sequence by severity. Septic shock is the more severe manifestation, so it is listed first as the principal diagnosis. The sepsis code then appears as a secondary diagnosis to reflect the underlying infection and systemic response. If the documentation also specifies the site of infection or the responsible organism, include those codes as well to fully describe the clinical picture. This approach ensures the record reflects both the life-threatening state and the underlying sepsis that led to it. Omitting sepsis or coding only septic shock would miss the underlying infection and the broader sepsis diagnosis, and sepsis is coded when documented even if septic shock is present.