Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is a severe infection of the ascitic fluid in patients with liver cirrhosis or other causes of ascites, without an obvious source of infection. It is characterized by bacterial translocation from the gut into the peritoneal cavity, leading to inflammation.

This code is used when documentation clearly indicates a diagnosis of spontaneous bacterial peritonitis, typically in patients with underlying liver disease and ascites. Supporting documentation will often include paracentesis results showing a high polymorphonuclear leukocyte (PMN) count in the ascitic fluid and positive bacterial cultures.

• Differentiate from secondary peritonitis, which has an identifiable intra-abdominal source of infection.
• Do not code with K65.9 (Bacterial peritonitis, unspecified) if SBP is specifically documented.
• Always code the underlying liver disease or other cause of ascites as a primary or secondary diagnosis.