sepsis new guidelines, new codes

SepsisNew Guidelines, New Codes

Barry Libman, RHIA, CCS, CCS-P

President

Barry Libman Inc.

Terms and Definitions

Bacteremia bacteria in the blood

Septicemia systemic disease with organisms or toxins in the blood (e.g.

bacteria, fungi, virus) Sepsis

Systemic inflammatory response to known or suspected infection

Severe Sepsis Sepsis plus organ dysfunction

SIRS Systemic response to infection to infection or trauma

Septic shock Sepsis with hypotension

790.7 Bacteremia

Presence of bacteria in the blood

Use additional code to identify organism (041)

Excludes Bacteremia of newborn (771.83)

038.x Septicemia

Infectious diseases due to the accumulation and persistence of bacteria and/or their toxins in the blood and marked by high fever, shaking chills, prostration, and if untreated hypotension, shock and death.

Only one code (038.x) is required to report Septicemia

Excludes Septicemia (sepsis) of newborn (771.81)

Septicemia and Sepsis

Septicemia and Sepsis are no longer synonymous terms

AHA Coding Clinic for ICD-9-CM, Fourth Quarter, 2003

Coding “Sepsis”

Sepsis requires two codes

Underlying condition 038.x

and

995.91 or 995.92

Per Instructional notes in Tabular Index.

995.9x SIRS

Systemic Inflammatory Response Syndrome

A major complication of infection and/or trauma that includes systemic inflammation, elevated or reduced temperature, rapid heart rate and respiration, and elevated white blood cell count that may progress into organ and multi-organ failure.

995.9x SIRS

Two or more of the following: Temperature >38 C or <36 C Heart Rate > 90 beats per minute Respiratory Rate > 20 breaths per minute or

PaCO2 < 32 mm Hg White Blood Cell Count > 12,000/cu mm,

<4,000/cu mm or >10% immature (band) forms

Source: Bone et al. Source: Bone et al. ChestChest 1992;101:1644 1992;101:1644

SIRS Continuum

SIRSINFECTION

PANCREATITIS

BURNS

TRAUMA

OTHER

SEPSIS

SEVERESEPSIS

SEPTICSHOCK

995.9x SIRS

995.90 SIRS, unspecified

995.91 … due to infectious process. Sepsis 995.92 … due to infectious process w/ organ

dysfunction. Severe Sepsis

995.93 … due to non-infectious process 995.94 … due to non-infectious process w/

organ dysfunction

995.9x SIRS sequencing

Code first the underlying cause

Use an infection or trauma code plus 995.9x (SIRS) to accurately reflect severity

In absence of underlying condition, 995.90 SIRS is used as the principal diagnosis

995.92 and 995.94

In presence of organ dysfunction use additional code to specify the organ dysfunction, e.g.: Acute renal failure (584.5-584.9 ) Acute respiratory failure (518.81) Critical illness myopathy (359.81) Critical illness polyneuropathy (357.82) Encephalopathy (348.31) Hepatic failure (570) Kidney failure (584.5-584.9, 585, 586) Septic shock (785.52)

995.9x SIRS sequencing

Sequence

1. underlying condition

2. SIRS 995.9x

3. any organ dysfunction

785.52 Septic Shock

Sepsis with sepsis-induced hypotension despite fluid resuscitation and inadequate tissue perfusion (failure of peripheral circulation).

Code first SIRS due to infectious process with organ dysfunction (995.92)

Mortality

Septic Shock

53-63%

20-53%Severe Sepsis300,000

7-17%Sepsis

400,000

Incidence

Source: Balk, R.A. Crit Care Clin 2000;337:52

Mortality Increases in Septic Shock Patients

Approximately 200,000 patients including 70,000 Medicare patients have septic shock annually

SIRS Therapies – Procedure Codes

00.11 Infusion Of Drotrecogin Alfa (Activated) Infusion of recombinant protein XigrisTM add-on payments will not be continued in

FY05 (no longer a new technology)

00.14 Injection or Infusion of Oxazolidinone Class of Antibiotics Linezolid injection ZyvoxTM

V09.x Resistance to Microorganisms

Drug Resistant Organisms

Resistance to Methicillin  V09.0

Other common drug resistance?

Example: Bacteremia

Bacteremia (cause unknown) Blood cultures growing E coli per MD

documentation

790.7 Bacteremia

041.4 E coli organism

Example: Bacteremia

Bacteremia  associated with/due to urinary tract infection

599.0  UTI

790.7  Bacteremia

790.7 is from Chapter 16 Signs, Symptoms and ill Defined Conditions. Follow chapter specific coding rule

Example: Streptococcal Septicemia/Sepsis Streptococcal Septicemia

(documented as septicemia)

038.0

Streptococcal Sepsis

(SIRS and documented infection)

038.0

995.91

Example: SIRS

SIRS due to 3rd degree burns and trauma

942.39  Third degree burn, trunk

808.43  Pelvic fracture

995.93 SIRS (not infectious, no organ dysfunction)

Example: SIRS

SIRS due to acute pancreatitis

577.0 Acute Pancreatitis

995.93 SIRS (no-infection, without organ dysfunction)

Example: SIRS

Acute pancreatitis with SIRS and hepatorenal syndrome

577.0 Acute pancreatitis

995.94 SIRS (no infection, with organ dysfunction)

572.4 Hepatorenal syndrome

Example: SIRS

A patient with chronic renal failure on chronic dialysis admitted for treatment of gram negative sepsis

038.49 Gram negative sepsis

995.91 SIRS (infection, no organ failure)

585 Chronic Renal Failure

V45.1 Dialysis status

Example: Septic Shock

A patient is discharged with the diagnosis of MRSA Septicemia with septic shock.

038.11  MRSA Septicemia

995.92  SIRS (infection, organ dysfunction)

785.52  Septic shock

V09.0 Resistance to Methicillin

(by definition, septic shock is an organ dysfunction)

Not covered in Coding Clinic (yet):

A patient is admitted to the hospital in respiratory failure due to pseudomonas pneumonia and placed on a ventilator.  Ten days into the hospital stay the patient develops pseudomonas sepsis.  The patient receives intravenous ZyvoxTM.

518.81 Respiratory Failure

482.1 Pseudomonas pneumonia

038.43 Pseudomonas sepsis

995.91 SIRS (infection, no organ dysfunction)

00.14 ZyvoxTM Infusion

Not covered in Coding Clinic (yet):

Patient admitted with Respiratory Failure due to Aspiration Pneumonia and SIRS (severe sepsis) 518.81, 995.92, 507.0

OR 038.9, 995.92, 518.81, 507.0?

Until we get Coding Clinic guidance: Cause is important – what caused the respiratory

failure? Severe sepsis, or pneumonia? Respiratory Failure is included in severe sepsis

(though coded separately)

Not covered in Coding Clinic (yet):

Line Sepsis 996.62, 038.9, 995.91

OR 038.9, 995.91, 996.62 ?

Based on previous guidance, the complication code is sequenced first. Similar to the “poisoning” chapter, the case is classified and coded to the Complications chapter.

What can you do?

Why does it getting it right matter? Severity of illness Statistics Reimbursement

What can you do? Work to improve documentation Talk to infectious disease staff Talk to trauma staff Talk to ICU intensivists

Questions?

Barry Libman, RHIA, CCS, CCS-P

Barry Libman Inc.

978-369-7180

blibman@barrylibmaninc.com