Download Sepsis - acdis

CDI and Coding Considerations
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•
Announced
at the SCCM
meeting in
Orlando on
February 22,
2016
Published in
JAMA on
February 23,
2016
http://www.tinyurl.com/2016sepsis
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The SIRS Criteria is valid to the extent that a
systemic inflammatory response can be
triggered by a variety of infectious and noninfectious conditions.
*Signs and Systemic Inflammatory do occur in
the absence of infection. For Example Burns,
Pancreatitis and other disease states.
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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 nonhomeostatic 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.
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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
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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.
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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”
SOFA score
alone does
not give me
the words
serving as
“acute organ
dysfunctions”
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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)
SOFA score
alone does
not give me
the words
serving as
“acute organ
dysfunctions”
SOFA score
alone does
not give me
the words
serving as
“acute organ
dysfunctions”
.
.
.
.
.
.
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
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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 coagulasenegative staphylococcus sepsis, and respiratory failure
– Since the sepsis is resolving would it be appropriate to code sepsis as the principal
diagnosis?
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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
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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
Principal Diagnoses Qualifying for MS-DRG 870-872, Sepsis
A021
A207
A227
A267
A327
A391
A392
A393
A394
A398
9
A399
A400
A401
A403
A408
A409
A410
1
A410
2
A411
A412
A413
Salmonella sepsis
Septicemic plague
Anthrax sepsis
Erysipelothrix sepsis
Listerial sepsis
Waterhouse-Friderichsen syndrome
Acute meningococcemia
Chronic meningococcemia
Meningococcemia, unspecified
Other meningococcal infections
Meningococcal infection, unspecified
Sepsis due to streptococcus, group A
Sepsis due to streptococcus, group B
Sepsis due to Streptococcus
pneumoniae
Other streptococcal sepsis
Streptococcal sepsis, unspecified
Sepsis due to Methicillin susceptible
Staphylococcus aureus
Sepsis due to Methicillin resistant
Staphylococcus aureus
Sepsis due to other specified
staphylococcus
Sepsis due to unspecified
staphylococcus
Sepsis due to Hemophilus influenzae
Gram-negative sepsis, unspecified
Sepsis due to Escherichia coli [E. coli]
Sepsis due to Pseudomonas
Sepsis due to Serratia
Other Gram-negative sepsis
Sepsis due to Enterococcus
Other specified sepsis
Sepsis, unspecified organism
Actinomycotic sepsis
Gonococcal sepsis
Disseminated herpesviral disease
Candidal sepsis
Hypovolemic shock
Other shock
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 shock
*
R6521* Severe sepsis with septic shock
*
R7881* Bacteremia
* As a Chapter 18 “symptom code”, it cannot be the PDx
if the underlying condition is known
A4150
A4151
A4152
A4153
A4159
A4181
A4189
A419
A427
A5486
B007
B377
R571*
R578*
R6510*
*
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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.
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.
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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.
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.
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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.
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Query if clinical indicators are present
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Underlying infection
Febrile, WBC
SIRS criteria Met
Other findings supporting the potential dx
Conflicting data
Procedures r/t to
End Organ
BPA fires
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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
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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
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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
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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
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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
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.
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 [email protected]. 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 [email protected]. 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 [email protected]. 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.
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
[email protected]. 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 sepsis
UTI only
Other _____________________
Unable to determine
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
[email protected]. 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.
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 [email protected]. 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.
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.
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.
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.
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.
QUESTIONS?
Thanks for your
time!