SEPSISCDI and Coding Considerations

Sepsis Redefinition (Sepsis-3)February 23, 2016

• Announced at the SCCM meeting in Orlando on February 22, 2016

• Published in JAMA on February 23, 2016

http://www.tinyurl.com/2016sepsis

The SIRS Criteria is valid to the extent that a systemic inflammatory response can be triggered by a variety of infectious and non-infectious conditions.

*Signs and Systemic Inflammatory do occur in the absence of infection. For Example Burns, Pancreatitis and other disease states.

Sepsis RedefinitionFebruary 23, 2016• Sepsis is now defined as a ‘life-

threatening organ dysfunction due to a dysregulated host response to infection’– In this new definition the concept of the non-

homeostatic host response to infection is strongly stressed while the SIRS criteria have been removed

– The inflammatory response accompanying infection (pyrexia, neutrophilia, etc) often represent an appropriate host response to any infection, and this may not necessarily be life-threatening.

• Specify if patient has “Probable, possible or suspected” sepsis on admission. The physician’s opinion of clinical sepsis should be documented. Positive blood cultures are not necessary per Coding Clinic Guidelines

• Do not use “Urosepsis” if the patient’s condition is sepsis (definitive or suspected) from a urinary tract source. Urosepsis is an ambiguous term that classifies and codes to UTI.

• Bacteremia is not synonymous with a sepsis diagnosis

Sepsis

Sepsis RedefinitionFebruary 22, 2016

• Septic shock is now defined as a ‘subset of sepsis where underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality’. – Clinical criteria identifying such condition include the need

for vasopressors to obtain a MAP≥ 65mmHg AND an increase in lactate concentration > 2 mmol/L, despite adequate fluid resuscitation.*

– This new definition is mainly focused on the importance to both distinguish septic shock from other forms of circulatory shock and underline the detrimental clinical impact of sepsis-induced cellular metabolism abnormalities.*

* Doesn’t mean one can’t have other forms of shock (e.g. cardiogenic, hypovolemic, or obstructive shock); if these are present, then they should be documented.

Sepsis RedefinitionFebruary 23, 2016• The key element of sepsis-induced organ

dysfunction is defined by ‘an acute change in total SOFA score ≥ 2 points consequent to infection, reflecting an overall mortality rate of approximately 10%– The baseline Sepsis-related Organ Failure Assessment

(SOFA) score may be taken as zero unless the patient is known to have previous comorbidity (e.g. head injury, chronic kidney disease, etc.)

– In light of this, the current definition of 'severe sepsis' becomes obsolete, as does the term “SIRS”

Coding ImplicationsSevere Sepsis

SOFA score alone does not give me the words serving as “acute organ dysfunctions”

Distinguish the terms for the presence of an organism in the blood as: Bacteremia (patient may not be symptomatic) and Sepsis (patient typically is symptomatic).

Sepsis = SIRS due to infection. That doesn’t mean if the patient meets the SIRS criteria they necessarily have Sepsis.

Lactate Levels > 2.0 mmol/L (>4.0 is equivalent to septic shock)

Sepsis

Coding ImplicationsSevere Sepsis

SOFA score alone does not give me the words serving as “acute organ dysfunctions”

Coding ImplicationsSevere Sepsis

SOFA score alone does not give me the words serving as “acute organ dysfunctions”

Endorsing Entities.

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Coding ImplicationsICD-10-CM

While Sepsis-3 requires acute organ dysfunction to define sepsis, a provider must document “severe sepsis” or link the organ dysfunction to sepsis to obtain a code for severe sepsis

MS-DRG 870-872 ValidityBefore and After Sepsis-3

Coding Clinic, 1st Q, 2012, p.19Sepsis Validity• Question: The patient was transferred to the long term care hospital

(LTCH) following a lengthy hospitalization for sepsis and acute respiratory failure– She was transferred to the LTCH for further intravenous antibiotic treatment and

management of her multiple medical problems including resolving coagulase-negative staphylococcus sepsis, and respiratory failure

– Since the sepsis is resolving would it be appropriate to code sepsis as the principal diagnosis?

• Answer: The Editorial Advisory Board (EAB) for Coding Clinic has become aware of a pattern of documentation problems concerning patients transferred to the LTCH with a diagnosis of sepsis– Physician advisers reviewing these cases did not agree that these patients were

truly septic since they had no clinical indicators– If the documentation is unclear as to whether the

patient is still septic, query the provider for clarification

– Facilities should work with the medical staff to improve physician documentation and address any documentation issues

Coding ImplicationsBefore and After Sepsis-3• Before Sepsis-

3– A systemic

infection code (e.g. A41.9) could be coded without a R65.2x code and still be considered valid if reasonable criteria are met

• After Sepsis-3– It is Dr. Kennedy’s opinion that if • the systemic infection code (e.g. A41.9) is

coded without a R65.2x code OR• an organ dysfunction code is not

documented to be associated with sepsis AND/OR it is not coded at all

that a code for sepsis can be legitimately challenged as a valid diagnosis since no organ dysfunction is present

– That if the systemic infection code or the R65.2x code is not POA that the systemic infection code (e.g. A41.9) cannot be the principal diagnosis

MS-DRG 870-872 ValidityBefore and After Sepsis-3

A021 Salmonella sepsisA207 Septicemic plagueA227 Anthrax sepsisA267 Erysipelothrix sepsisA327 Listerial sepsisA391 Waterhouse-Friderichsen syndromeA392 Acute meningococcemiaA393 Chronic meningococcemiaA394 Meningococcemia, unspecifiedA3989 Other meningococcal infectionsA399 Meningococcal infection, unspecifiedA400

Sepsis due to streptococcus, group A

A401

Sepsis due to streptococcus, group B

A403

Sepsis due to Streptococcus pneumoniae

A408 Other streptococcal sepsisA409 Streptococcal sepsis, unspecifiedA4101

Sepsis due to Methicillin susceptible Staphylococcus aureus

A4102

Sepsis due to Methicillin resistant Staphylococcus aureus

A411

Sepsis due to other specified staphylococcus

A412

Sepsis due to unspecified staphylococcus

A413

Sepsis due to Hemophilus influenzae

A414 Sepsis due to anaerobes

A4150 Gram-negative sepsis, unspecifiedA4151 Sepsis due to Escherichia coli [E. coli]A4152 Sepsis due to PseudomonasA4153 Sepsis due to SerratiaA4159 Other Gram-negative sepsisA4181 Sepsis due to EnterococcusA4189 Other specified sepsisA419 Sepsis, unspecified organismA427 Actinomycotic sepsisA5486 Gonococcal sepsisB007 Disseminated herpesviral diseaseB377 Candidal sepsisR571* Hypovolemic shockR578* Other shockR6510**

Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction

R6511**

Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction

R6520** Severe sepsis without septic shockR6521** Severe sepsis with septic shockR7881* Bacteremia * As a Chapter 18 “symptom code”, it cannot be the PDx if the underlying condition is known** Can never be the PDx according to the ICD-10-CM Guidelines

Principal Diagnoses Qualifying for MS-DRG 870-872, Sepsis

Criteria for SIRS must meet two or more of the following:

Fever > 38.3°C or hypothermia < 35° C, Hypotension Leukocytosis-WBC > 12,000 or leukopenia, WBC < 4,000

or >10% bands Tachycardia->90 beats/minute Tachypnea-RR > 20 breaths/minute or PaCO2 <

32mmHg

***Because tachypnea and tachycardia are so common in hospitalized patients for many reasons, they should not ordinarily be used as the only two criteria for diagnosing sepsis.

Sepsis

Altered Mental Status Mottling of the skin or prolonged capillary

refill Non-diabetic hyperglycemia (blood Sugar

>120) Other evidence of acute organ failure

(severe sepsis)***The diagnosis of sepsis depends entirely

on the physician’s clinical interpretation of these criteria and their significance.

Sepsis

If these findings can, in the physician’s judgment, be “easily explained by another coexisting condition (other than the underlying infection), it should be excluded by the physician when deciding whether the patient has sepsis.

Sepsis

Ask? Is it Severe, with shock, with a localized

infection, POA, due to post procedural infection, Bacteremia vs. Sepsis (presence of bacteria in the blood

Sirs is not synonymous with sepsis. If sirs occurs in presence of sepsis make sure to include both terms.

Sepsis ICD 10 tips

Sepsis is coded with only code (A41.9 is for unspecified sepsis). Severe sepsis requires a code for sepsis (A41.9), followed by the code for sever sepsis (R65.20), with an additional code to identify the specific acute organ dysfunction.

In ICD-10, Sepsis must be specifically diagnosed since there is no code for “SIRS due to infection” as in ICD-9. ICD-10 has no code for urosepsis and provider must be queried.

Sepsis

Query if clinical indicators are present◦ Underlying infection◦ Febrile, WBC◦ SIRS criteria Met◦ Other findings supporting the potential dx◦ Conflicting data◦ Procedures r/t to ◦ End Organ

BPA fires

Query

Tissue hypoperfusion persistent after fluid administration evidenced by any of the following conditions: ◦ Systolic blood pressure below 90◦ Mean arterial pressure below 65◦ A decrease in systolic blood pressure by more

than 40 points◦ Lactate level over 4 mmol/L◦ Blood cultures◦ Antibiotics

Septic Shock Presentation

Crystalloid fluids administered .9% NS or Lactated Ringers.

Watch for documentation of Hypotension:◦ Systolic BP lower than 90◦ Mean arterial pressure lower than 65 ◦ A decrease in systolic blood pressure by more

than 40 points◦ If hypotension persists after fluid is given, look for

the administration of IV Vasopressor ◦ Heart and Lung Assessment findings

Sepsis

Conflicting Documentation The documentation of the attending provider supersedes

that of all other providers; however, many organizations allow individual providers within the same practice to “share” the role of the attending provider.

The role of the attending providers and the relationship with “consulting” providers has drastically changed in recent years as the attending more often coordinates care and defers to the consulting provider for specific guidance on specific conditions.

Information obtained from the following sources: HcPro, Acdis

AHIMA/ACDIS 2013 Query Recommendation Is conflicting, imprecise, incomplete, illegible,

ambiguous, or inconsistent Describes or is associated with clinical indicators

without a definitive relationship to an underlying diagnosis

Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure

Provides a diagnosis without underlying clinical validation

Is unclear for present on admission indicator assignment

Information obtained from the following sources: HcPro, Acdis, AHIMA

Are any of the following organ dysfunction criteria present at a site remote from the site of the infection that are not considered to be chronic conditions?

Acutely altered mental status SBP less than 90 or MAP less than 65 mmHg SpO2 less than 90% on room air or on supplemental O2 Creatinine greater than 2 mg/dL (176.8 mmol/L) or Urine

Output less than 0.5 mL/Kg/hour for greater than 2 hours Bilirubin greater than 2 mg/dL (34.2 mmol/L) Platelet count less than 100,000 μL Lactate greater than 4 mmol/L

Sepsis

Build a query for a diagnosis of SIRS and/or sepsis for the following scenario: The patient was admitted for an infection urinary tract infection (UTI), Pyelonephritis (PNA) and meets two SIRS criteria. The patient may be treated with oral or intravenous antibiotics, and may be on a general medical floor (not intensive care). The physician did not document SIRS or sepsis.

Developing Queries for Sepsis

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.- See more at: http://blogs.hcpro.com/acdis/?s=SEPSIS&x=0&y=0#sthash.vx2PsZJS.dpuf

Would this be considered adding new information to the chart, leading the physician, by introducing a new diagnosis?

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.- See more at: http://blogs.hcpro.com/acdis/?s=SEPSIS&x=0&y=0#sthash.vx2PsZJS.dpuf

“Providing a new diagnosis as an option in a

multiple choice list, as supported and

substantiated by referenced clinical

indicators from the health record, is not

introducing new information.”Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.- See more at: http://blogs.hcpro.com/acdis/?s=SEPSIS&x=0&y=0#sthash.vx2PsZJS.dpuf

If you have a patient that demonstrates clinical indicators to support the diagnosis of sepsis, you may submit a query to clarify if this diagnosis is appropriate. In the body of the query, you would also include those clinical indicators and evidence of treatment that supports your rational for querying the physician.

Reverse Queries

Use the SIRS criteria to support sepsis, with caution. The criteria cannot be explained by another existing condition—for example, tachycardia when the patient has atrial fibrillation. Review the Surviving Sepsis Campaign’s nationally supported clinical criteria and treatment bundles that can be used to support the diagnosis of sepsis.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.- See more at: http://blogs.hcpro.com/acdis/?s=SEPSIS&x=0&y=0#sthash.vx2PsZJS.dpuf

Patient 2345 was admitted with a UTI. The ED record indicates

patient was febrile with a temperature of 102.7, heart rate of 98, Laboratory results showed a white blood cell count of 13,500 with 12% bands, hyperlactatemia, and altered mental status. Blood cultures pending. Antibiotics ordered with fluid bolus.

Based on these clinical indicators, can the patient’s status be further clarified as:

UTI with sepsisUTI onlyOther _____________________Unable to determine

Query Example

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.- See more at: http://blogs.hcpro.com/acdis/?s=SEPSIS&x=0&y=0#sthash.vx2PsZJS.dpuf

There’s sepsis and there’s alternative terms that are not sepsis.

Putting a patient on a “sepsis protocol” is not a diagnosis of sepsis. A sepsis protocol says the patient may have an infection and it may have advanced far enough to be serious and have systemic manifestations with increased risk of death, or it may turn out, after workup, that it wasn’t sepsis at all, or it may not be an infection at all.

Scenarios

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.- See more at: http://blogs.hcpro.com/acdis/?s=SEPSIS&x=0&y=0#sthash.vx2PsZJS.dpuf

A patient who has criteria of systemic inflammatory response syndrome (SIRS) has abnormalities in vital signs or abnormalities of lab tests. That alone is not sepsis under any circumstances—until it’s proven to be sepsis. Most patients do not exhibit the clinical indicators to even meet the criteria and, in many that did meet the criteria, the abnormalities had nothing to do with the infection.

Scenario

Acute diverticulitis is acute diverticulitis. Acute otitis media is acute otitis media. Most bacterial infections have two of the four criteria of SIRS and most of these patients are not sick. Most patients seen in an emergency room with an infection and two of the four criteria that look like SIRS actually go home.

Scenarios

Using the term “sepsis syndrome” is another way of trying to get around truth. Once upon a time, “sepsis syndrome” actually meant sepsis; however it has evolved to be equivalent to SIRS and has no validity as a codable term at all until, and if, it is determined that the patient has actually has sepsis. In fact, Coding Clinic even came to that conclusion in Second Quarter 2012 p. 21, and people who are assigning sepsis codes based on documentation of “sepsis syndrome” are taking quite a risk.

Scenarios

Acute diverticulitis is acute diverticulitis. Acute otitis media is acute otitis media. Most bacterial infections have two of the four criteria of SIRS and most of these patients are not sick. Most patients seen in an emergency room with an infection and two of the four criteria that look like SIRS actually go home.

Scenarios

Using the term “sepsis syndrome” is another way of trying to get around truth. Once upon a time, “sepsis syndrome” actually meant sepsis; however it has evolved to be equivalent to SIRS and has no validity as a coded term at all until, and if, it is determined that the patient has actually has sepsis. In fact, Coding Clinic even came to that conclusion in Second Quarter 2012 p. 21, and people who are assigning sepsis codes based on documentation of “sepsis syndrome” are taking quite a risk.

Scenarios

QUESTIONS?

Thanks for your time!