A48.3

Billable

Toxic shock syndrome

HCC Category Mapping

V28HCC 2 — Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock

0.455

V24HCC 2 — Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock

0.455

ESRDHCC 2 — Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock

0.000

What This Code Means

Toxic shock syndrome is a rare but serious condition caused by bacterial toxins that enter the bloodstream, leading to a sudden drop in blood pressure, high fever, and potential organ failure. It can develop rapidly and requires immediate medical treatment.

Coding Tips

•Always verify the causative organism (Staphylococcus aureus or Streptococcus pyogenes) in the medical record and code additional organism codes if documented
•Ensure you capture any associated complications such as acute kidney injury, sepsis, or organ dysfunction with additional ICD-10-CM codes, as toxic shock syndrome often presents with multi-system involvement

Clinical Significance

Toxic shock syndrome is a high-acuity, life-threatening condition that maps to one of the highest-weighted HCCs in risk adjustment. Accurate capture is critical because it reflects significant acute illness burden and resource utilization. This diagnosis demands immediate clinical intervention and carries substantial mortality risk.

Documentation Requirements

✓Identification of causative organism (Staphylococcus aureus or Streptococcus pyogenes) with culture results
✓Clinical criteria met: fever >=102F, hypotension (systolic BP <=90 mmHg), diffuse macular rash with desquamation
✓Multi-organ involvement documented (e.g., renal, hepatic, hematologic, CNS dysfunction)
✓Source of infection (wound, tampon use, surgical site, post-partum)
✓Severity indicators: vasopressor requirements, ICU admission, mechanical ventilation

Excludes 1 — Do NOT code together

endotoxic shock NOS (R57.8)
sepsis NOS (A41.9)

Use Additional Code

code to identify the organism (B95, B96)

Commonly Confused Codes

A41.9 (Sepsis, unspecified organism) — Sepsis is a systemic infection response but toxic shock syndrome specifically requires toxin-mediated shock with the classic triad of fever, hypotension, and rash; TSS is toxin-driven, not bacteremia-driven R65.21 (Severe sepsis with septic shock) — While both involve hemodynamic instability, TSS has a distinct toxin-mediated pathophysiology with characteristic desquamating rash that differentiates it from septic shock T81.12 (Postprocedural septic shock) — Postoperative shock from infection but lacks the specific toxin-mediated mechanism and rash criteria of TSS

Code Hierarchy

└A48Other bacterial diseases, not elsewhere classified └A48.3Toxic shock syndrome

└A48.3Toxic shock syndrome