Sepsis following incomplete spontaneous abortion

This code signifies a systemic inflammatory response syndrome (SIRS) due to infection, specifically occurring after a spontaneous abortion where not all products of conception have been expelled. It indicates a severe infectious complication arising from retained gestational tissue.

Apply this code when documentation clearly states sepsis or septicemia in a patient who has experienced an incomplete spontaneous abortion. Supporting documentation would include evidence of infection (e.g., fever, elevated white blood cell count, positive cultures) and clinical signs of SIRS following the incomplete abortion.

• Ensure documentation explicitly links the sepsis to the incomplete spontaneous abortion.
• Do not code with O03.2 if the sepsis is due to a septic or septicopyemic embolism.
• Sequence this code as the principal diagnosis when the sepsis is the primary reason for the encounter.