A recent discussion regarding lactic acidosis in a patient with sepsis has prompted a review of some important points that need clarification.  

First and foremost, lactic acidosis is not considered inherent to Sepsis. Additionally, acidosis is not noted as an excludes 1 or excludes 2 note under code category “A41” – Other Sepsis. 

A query would certainly be appropriate if the patient has elevated lactate and has met the criteria of a secondary diagnosis. 

But don’t stop here; there is more to it! 

Under category E87, “Other disorders of fluid, electrolyte, and acid-base balance” in the 2023 ICD-10-CM manual, the codes are as follows:  

E87.2 Acidosis  

Excludes1: diabetic acidosis – see categories E08-E10, E11, E13 with ketoacidosis  

E87.20 Acidosis, unspecified  

Lactic acidosis NOS  Metabolic acidosis NOS  
Code also, if applicable, respiratory failure with hypercapnia (J96. with 5th character 2)  

E87.21 Acute metabolic acidosis  

Acute lactic acidosis  

E87.22 Chronic metabolic acidosis  

Chronic lactic acidosis  
Code first underlying etiology, if applicable  

E87.29 Other acidosis  

Respiratory acidosis NOS 
Excludes 2: acute respiratory acidosis (J96.02) chronic respiratory acidosis (J96.12) 

It is important to note the codes above are CCs and may change the SOI/ROM; however, in a septic patient, these diagnoses will most likely not affect the DRG itself. 

This is very valuable information with regard to quality initiatives that may be important to your organization.  This could indicate an increased severity of illness and support a longer length of stay.  Consequently, this is one of the main reasons why many healthcare facilities are querying for acidosis in the presence of sepsis.  

So, when do you query for lactic acidosis outside of the usual elevation of lactic acid in sepsis?  

According to the ACDIS document  (https://acdis.org/articles/qa-lactic-acidosis-and-sepsis) 

Q&A: Lactic acidosis and sepsis 

May 30, 2019 – CDI Strategies – Volume 13, Issue 24 

“From a clinical standpoint, any patient with severe sepsis would be expected to have elevated lactate levels; they would not, however, be expected to always have a large anion gap and persistent levels of lactate > 5mmol/l after hydration. In fact, such a patient would be considered by many definitions (Sepsis-3 included) to be in septic shock.”

The article goes on to clarify when it would be appropriate to query and address the important query questions to ask. 

To summarize: 

1. If the lactic acid levels are mild, they would be considered part of the sepsis diagnosis and not reportable under ICD-10 CM. 
2. If the lactic acid level is out of sync with the severity of the sepsis (a radically elevated lactic acid without severe sepsis or septic shock), a query to determine the underlying cause of the lactic acidosis would be appropriate.   If another underlying cause is found, the acidosis may be reportable as long as it is not expected in the other associated diagnosis. 
3. Septic shock, with severely elevated lactate levels and anion gap, would also be routinely associated with septic shock and not reportable using basic coding guidelines.   

In closing, let’s review some considerations for queries: 

• Before querying lactic acidosis in conditions such as sepsis and respiratory failure, consider if the elevated lactic acid would be routinely associated with the diagnosis. 
• Also, consider if there could be another underlying cause for the elevation and if it is considered to be routinely associated with those diagnoses.   
• Then use your best critical thinking skills and your organization’s guidelines to determine if a query for lactic acidosis is compliant in that situation.