septicemia/sepsis slides

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Documentation, Coding Audit, and Appeal Workshops

Sponsored by Intersect Healthcare Inc

Part One: Septicemia/Sepsis Workshop

(MS-DRG’s 870, 871-872)

Sponsored by Intersect Healthcare, Inc.

(MS DRG s 870, 871 872)

Next Session:Wednesday, June 23

1 00PM EST1:00PM ESTRespiratory Failure

with Ventilator Support

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Part One: Septicemia/Sepsis Workshop

(MS DRG’ 870 871 872)


(MS-DRG’s 870, 871-872)

Your Panel:

Joel Moorhead, MD, PhD 1:00-1:30 pmDocumenting Septicemia/Severe Sepsis

Charmira Johnson, CCS, BS, LPN, CCDS 1:30-2:00 pmCoding/Audits for Septicemia/Severe Sepsis

Denise Wilson, RN, RRT, MS 2:00-2:30 pm Appealing Septicemia/Severe Sepsis Takebacks

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Joel Moorhead, MD, PhDAdjunct Associate Professor

Rollins School of Public Health Emory University

Atlanta, GA

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• Documentation to support diagnosis of • Documentation to support diagnosis of SIRS and sepsis

• Infectious versus non-infectious SIRS

First Things First Planning• Severe sepsis

• SIRS with organ dysfunction

• Associated conditions

(c) 2010 Intersect Healthcare, Inc. 4

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• Inflammation is body’s NORMAL response • Inflammation is body s NORMAL response to infection, chemical exposure, or trauma

– Stage I: Initiation of inflammatory response

First Things First Planningp

• WBCs secrete proteins (cytokines) that promote healing

– Chemical messengers that promote tissue repair

– Stage II: Control of local inflammatory response

• Decrease in chemicals that promote inflammation• Increase in chemicals that reduce inflammation• Homeostasis maintained

– Bone RC. Critical Care Medicine 1996;24:163-172


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– Inflammation Stage III• Body loses control• Homeostasis cannot be restored• Cytokine activity becomes destructive

– Capillaries damaged– Multiple organs may be damaged

First Things First Planning» Bone RC. Critical Care Medicine 1996;24:163-172


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• Age >65Age >65• Immunosuppression

– Steroids, chemotherapy, immunosuppressant drugs– AIDS and other chronic immunological disorders

• Alcohol abuse

First Things First Planning• Malnutrition• Invasive instrumentation• Persistent inflammatory or infectious focus• Chronic disease, e.g. COPD, DM, CAD, renal f ilfailure

• Kohl BA and Deutschman CS. Current Opinion in Critical Care 2006;12:325‐332


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• Infection• Infection– Inflammatory response caused by

microorganisms

• Bacteremia– Bacteria in the blood

First Things First Planning• SIRS– Inflammatory response, independent of

cause

• Sepsis– SIRS arising from infectionSIRS arising from infection

– Bone RC et al. Chest 1992;101:1644-1655


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• 995 9 Systemic Inflammatory • 995.9 Systemic Inflammatory Response Syndrome (SIRS)– 995.91 Sepsis

• SIRS due to infectious process without acute organ dysfunction

– 995.92 Severe sepsis

First Things First Planning995.92 Severe sepsis

• Sepsis with acute organ dysfunction• Sepsis with multiple organ dysfunction (MOD)

– 995.93 SIRS due to non-infectious process without acute organ dysfunction

– 995.94 SIRS due to non-infectious process with acute organ dysfunction


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• ACCP/SCCM Consensus Conference (1991)(1991)

• SCCM/ESICM/ACCP/ATS/SIS Consensus Conference (2001)– ACCP: American College of Chest Physicians– SCCM: Society of Critical Care Medicine

First Things First PlanningSCCM: Society of Critical Care Medicine

– ESICM: European Society of Intensive Care Medicine

– ATS: American Thoracic Society– SIS: Surgical Infection Society

Copyright 2009 5 (c) 2010 Intersect Healthcare, Inc. 10

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1991 ACCP/SCCM 2001 ACCP/SCCM…Update• Infection with at least

two of the following, not due to other cause:

– Temp >38° C or <36 ° C

• Infection documented or suspected and “some of ” …– General parameters

• Temp >38.3° C or <36 ° C• HR >90 or 2 SD > age mean

• >100.4° F or <96.8 ° F

– HR >90 per minute– Hyperventilation– RR >20 per minute– PaCO2 <32 mm Hg– WBC >12,000 or <4000

• RR >30 per minute

– Inflammatory parameters• WBC >12,000 or <4000 /μL • Or >10% bands

– Hemodynamic parametersTissue perfusion parameters/μL

• Or >10% bands– Bone RC et. al., Chest

1992;101:1644-1655

– Tissue perfusion parameters– Levy MM et al for the International

Sepsis Definitions conference. Intensive Care Medicine 2003;29:530-538


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• Fever (core temperature >38.3° C)• Hypothermia (core temperature <36° C)• HR >90 or >2 SD above normal value for age• Tachypnea: >30 per minute

Alt d t l t tFirst Things First Planning

• Altered mental status• Significant edema or positive fluid balance• Hyperglycemia (>110 mg/dl in absence of DM)

– Levy MM et al for the International Sepsis Definitions conference. Intensive Care Medicine 2003;29:530-538


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• Leukocytosis (WBC >12,000/ /μL)• Leukopenia (WBC <4000 /μL)• Normal WBC with >10% immature forms

– Usually reported as “Bands”

First Things First Planning• Plasma C reactive protein >2 SD above normal• Plasma procalcitonin >2 SD above normal

– Levy MM et al for the International Sepsis Definitions conference. Intensive Care Medicine 2003;29:530-538


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• Hypotension (Psys<90 mm Hg or ↓>40 mm Hg)Hypotension (Psys<90 mm Hg or ↓>40 mm Hg)• Organ dysfunction parameters

– Number of failing organs or composite score (e.g. MODS)

• Hypoxemia (PaO2/FIO2 <300)• Acute Oliguria (urine output <0.5 ml/kg/h 24 h)

First Things First PlanningAcute Oliguria (urine output <0.5 ml/kg/h 24 h)

• Creatinine increase ≥0.5 mg/dl• Coagulopathy (INR >1.5 or activated PTT >60

seconds)• Ileus (absent bowel sounds)• Thrombocytopenia (platelet count <100 000/μl)• Thrombocytopenia (platelet count <100,000/μl)• Hyperbilirubinemia (plasma total bilirubin >4

mg/dl)– Levy MM et al for the International Sepsis Definitions conference.

Intensive Care Medicine 2003;29:530-538


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• Hyperlactatemia (>3 mmol/l)

• Decreased capillary refill or mottling• Levy MM et al for the International Sepsis Definitions conference. Intensive

Care Medicine 2003;29:530-538Care Medicine 2003;29:530 538


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• 995.9 Systemic Inflammatory Response Syndrome (SIRS)– 995.91 Sepsis


First Things First Planningdysfunction

– 995.92 Severe sepsis• Sepsis with acute organ dysfunction• Sepsis with multiple organ dysfunction (MOD)

– 995.93 SIRS due to non-infectious process without acute organ dysfunction

– 995.94 SIRS due to non-infectious process with acute organ dysfunction


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• Six measures, scale of 0 (normal) to 4 (marked derangement)

– Respiratory - PaO2/FIO2 ratio– Renal – Serum creatinine concentration– Hepatic – Serum bilirubin concentration– Hematologic – Platelet count

First Things First PlanningHematologic Platelet count

– Central nervous system – Glascow Coma Scale– Cardiovascular – HR x (central venous pressure/mean

arterial pressure)

• MOD score and hospital mortality– 9-12: 50% hospital morality

13 16: 70% hospital mortality– 13-16: 70% hospital mortality– 17-20: 82% hospital mortality– 21-24: 100% hospital mortality

– Marshall JC et al. Multiple Organ Dysfunction Score. Critical Care Medicine 1995;23(10):1638-1652


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• History of chronic organ insufficiency or immunocompromise?

• Acute renal failure?• Age• Vital signs

First Things First Planning– Temperature, HR, RR

• Lab values– pH, sodium, potassium, creatinine, hematocrit, WBC, PaO2,

alveolar-arterial O2 gradient

• Apache II score 21-25: Predicted mortality 50%; 26-30: 70%26-30: 70%

– Patients with sepsis may have higher-than-predicted mortality

– Lee KH et al. Singapore Med J 1993;34:41-44


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Organ System Sign of Dysfunction• Cardiovascular

P l

• ↑HR, ↓ BP, edema↓ capillary refill, skin mottling

• Tachypnea, hypoxemia• Pulmonary

• Renal

• Hepatic

Tachypnea, hypoxemia

• ↑ Creatinine, oliguria

• Hyperbilirubinemia

• Gastrointestinal • Ileus– Based on Levy MM et al for the

International Sepsis Definitions conference. Intensive Care Medicine 2003;29:530-538


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Organ System Sign of Dysfunction• Neurological

• Hematologic

• Altered mental status

• Leukocytosis, leukopenia, >10% bands, thrombocytopenia,

• General and Metabolic

thrombocytopenia, coagulopathy

• Fever, hypothermia, hyperglycemia, ↑ C-reactive protein↑ p

– Based on Levy MM et al for the International Sepsis Definitions conference. Intensive Care Medicine 2003;29:530-538


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99 92 S S i kid i j• 995.92 Severe Sepsis and

• 995.94 SIRS due to non-infectious process with acute organ dysfunction

• Acute kidney injury• Acute respiratory failure• Critical illness

myopathy• Critical illness

l thdysfunction– Code first underlying

infection– Use additional code to

specify acute organ dysfunction, such as …

polyneuropathy• Disseminated

intravascular coagulopathy syndrome

• EncephalopathyH ti f il• Hepatic failure


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• 995.9 Systemic Inflammatory Response Syndrome (SIRS)– 995.91 Sepsis


First Things First Planning– 995.92 Severe sepsis• Sepsis with acute organ dysfunction• Sepsis with multiple organ dysfunction (MOD)

– 995.93 SIRS due to non-infectious process without acute organ dysfunction995 94 SIRS d t i f ti ith – 995.94 SIRS due to non-infectious process with acute organ dysfunction


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b f i N i f ti diti • Lab tests favoring infectious SIRS (probably little help for coding)

– ↑ C-reactive protein– ↑ Procalcitonin (cytokine)– ↓ Eosinophil count

• Non-infectious condition →infection that results in SIRS, see Section 1.C.17.b.12.

– ICD-9 Official Guidelines for Coding and Reporting, Section 1.C.17.g

• If sepsis meets definition of principal diagnosis, sequence septicemia before the non-

• Only an issue if both infectious and noninfectious causes are present in same patient

septicemia before the noninfectious condition

• When both the non-infectious condition and the infectious condition (sepsis) meet the definition of principal diagnosis, either can be assigned as principal patient assigned as principal diagnosis.

– ICD-9 Official Guidelines for Coding and Reporting, Section 1.C.1.b.12.


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• Trauma • Surgery• Pancreatitis• Ischemia• Hemorrhagic shock• Immune-mediated

– Kohl BA, Deutschman CS. klCurr Opin Crit Care 2006;12:325-332

• Medications– Coding Clinic 1st Quarter 2010, pages 10-11

• Malignant neoplasm• Other types of

organ injury• Bone RC. JAMA 1992;268(24):3452-

3455

Other types of inflammatory conditions

– Coding Clinic 1st Quarter 2010, page 10


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• Aspiration P i (507 0)

• Autoimmune diPneumonia (507.0)

indexed under Category 507 Pneumonitis due to solids and liquids

diseases– Systemic lupus– Rheumatoid arthritis– Sarcoidosis

• Associated diti

q– No infectious examples – Aspiration + infection?

• If aspiration led to infectious pneumonia after admission, the infectious condition was not present on admission and was not eligible for principal diagnosis

conditions– Liver

• Hepatitis• Primary biliary cirrhosis

– Kidney• Nephritis• Glomerulonephritis

diagnosis.– GI

• Crohn’s disease• Ulcerative colitis

(c) 2010 Intersect Health care, Inc. 25

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• Risk factors– Prolonged rupture of

• Clinical syndrome– Signs of circulatory Prolonged rupture of

membranes– Pre-term labor– Maternal fever– Unhygienic postnatal

care

g ycompromise in first month of life

• Pallor, poor perfusion• Hypotonia• Poor responsiveness

– Low birth weight– Feeding of

contaminated foods and fluids

• PDx 771.81 Septicemia of newborn (not 038.xx)– 041.xx Bacterial infection– If applicable …

• 995.92 Severe sepsisAcute organ dysfunction code• Acute organ dysfunction code

– Edmond K, Zaidi A. PLoS Medicine 2010;7(3):e1000213


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SIRS SEPSIS• Antibiotics when

– Immunocompromised– Hemodynamically

unstable– Infection suspected

fl id

• Broad-spectrum antibiotics• Crystalloid, vasopressors

– Hypotension

• Low-dose steroids for septic shock• IV fluids, vasopressors

– Hypotension

• Treatment of complications

• Control of blood glucose levels

shock• Control blood glucose levels• Treatment of complications• Drotrecogin alfa (Xigris®)

– Recombinant protein C– Anti-thromboticglucose levels

• Oxygen• Burdette SD, Parilo MA.

Emedicine.medscape.com/article/168943-print

Anti thrombotic– Anti-inflammatory– Used when risk of mortality

high


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• 2004 Survey of 1058 physicians– Only 17% agreed on any one definition of sepsis

• Multiple signs and symptoms– None are specific for sepsis

First Things First PlanningNone are specific for sepsis

– All signs and symptoms can vary among patients and within the same patient over time

– Signs and symptoms should not be due to any other cause• But other causes are almost always present

– Acute organ dysfunction must be associated with sepsis• Elevated liver function tests in patient with autoimmune hepatitis

probably associated with hepatitis rather than sepsisprobably associated with hepatitis rather than sepsis

• Single definition of sepsis may never be possible• Vincent J-L et al . Evolving concepts in sepsis definition. Critical Care Clinics

2009;25:665-675


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• If the patient isn’t really sick, he or she probably i ’ iisn’t septic.

– Physicians almost always dictate a level of concern about a seriously ill patient.

• Look for basic consensus criteria to support diagnosis of sepsis.

• Clarify whether sepsis is secondary to an

First Things First PlanningClarify whether sepsis is secondary to an infectious or a non-infectious process.

• Look for conditions under all the parameters from the 2001 International Sepsis Definitions Conference to support the presence of acute organ dysfunction.

• Consider all diagnoses or medical terms corresponding to each organ dysfunction to identify all conditions eligible for coding.


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Charmira Orr, BS, LPN, CCS, CPC, CCDS Director of Coding and Audit Services

Intersect Healthcare, Inc.,

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• Understand how to apply the ICD-9 CM • Understand how to apply the ICD-9 CM coding and sequencing guidelines to assign related codes for Septicemia, SIRS, and Sepsis

First Things First Planning• The RAC, Septicemia, and Severe Sepsis

• Auditing the Medical Record for Septicemia, SIRS, and Sepsis documented diagnosis


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• Defined as a “systemic” condition or major complication that is associated with pathogenic organisms like fungi, bacteria, and etc. in the blood stream.

• O38* Series are MCC conditions • Other types of septicemia classified to another organism

can be found in the Index-under Septicemia such as conditions like Herpetic Septicemia 054 5 or Anthrax

First Things First Planningconditions like Herpetic Septicemia 054.5 or Anthrax Septicemia 022.3 also MCC Conditions

• It is an Infection from the entrance of the organisms in the blood

• Not to be confused with Bacteremia – in which is bacteria that has entered into the blood stream and if not stopped leads to the “systemic” infection that causes Septicemia

• Needs to be specifically documented by physician and alone does not mean the patient has Sepsis

• Can have negative or inconclusive blood cultures


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DRG RW GMLOSDRG 791 Prematurity RW 3.2039 GMLOS 0.0ywith Major Problems

MS‐DRG 974 HIV with Major Related Conditions with a MCC

RW 2.5656 GMLOS 7.3

MS‐DRG 870 Septicemia or Severe

h

RW 5.7258 GMLOS 12.9

Sepsis withMechanical Ventilation 96+ Hours

MS‐DRG 871Septicemia or Severe Sepsis w/o Mechanical Ventilation 96 + Hours with MCC

RW 1.8222 GMLOS 5.5

MS‐DRG 872 Septicemia or Severe Sepsis w/o Mechanical Ventilation 96+ hours w/o MCC

RW 1.1209 GMLOS 4.7


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• Systemic Inflammatory Response Syndrome• DEF: As a “acute” clinical response to an infection insult DEF: As a acute clinical response to an infection, insult,

or other trauma• Subcategory 995.9• When assigning must have two (2) codes to describe Can

never be assigned as a Principal Diagnosis- must sequence first the underlying cause then code 995.9

• Must monitor for Infection and Noninfectious process data

First Things First Planningwithin the medical record

• According to the American College of Chest Physicians and the Society of Critical Care Medicine, the clinical manifestations of SIRS include: Must Have at Least 2 of the manifestations to assign SIRS

– Temperature >38° or <36° C, rectally – Tachycardia >90 BPM– Tachypnea >20 breaths per minute or– arterial pCO2 <32mm Hg– WBC >12,000/mm2 or <4,000/mm2– or >10% band


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(c) 2010 Intersect Healthcare, Inc.

Infection SIRS SEPSIS

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• Defined as the body’s systemic inflammatory response to an infection in the body that can originate from anywhere in the body, however does not cause “acute” organ dysfunction

• Underlying infection can be suspected or proven infection• Two (2) or more of the clinical findings of SIRS not

attributable to any other cause• Infection + SIRS = SEPSIS

ICD 9 Code 995 91 excludes 995 90 SIRS NOS

First Things First Planning• ICD-9 Code 995.91 excludes 995.90 SIRS, NOS• IT is a MCC• Must be documented by the physician in order to assign

code• Minimum of two ( 2) codes for proper coding, with

underlying infection sequenced before 995.91


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• Severe Sepsis includes the same definitive data • Severe Sepsis- includes the same definitive data as Sepsis but extends to organ dysfunction. i.e. Acute renal failure (creatinine > 2 x ULN or baseline)

– ARDS (PaO2/FiO2 < 250)– DIC (thrombocytopenia— platelet count <100,000)

Encephalopathy

First Things First Planning– Encephalopathy– Hepatic failure (bilirubin or SGOT) – “Acute "Organ failure must be specifically documented that it is

related to Sepsis by the physician – Has a longer length of stay– Higher mortality rate– Often treated in ICU

• Minimum of three (3) codes sequencing first the underlying condition, then 995.92, then a additional code for the “acute” organ dysfunction


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• Issue Details Name Septicemia DRG 416, 576 MS-DRG 870, 871, 872 (At this time, Issue Details Name Septicemia DRG 416, 576 MS DRG 870, 871, 872 (At this time, Medical Necessity is excluded from review.) Number B000442009 Description The purpose of MS-DRG Validation is to determine that the principal diagnosis and all secondary diagnoses identified as CCs and MCCs are actually present, correctly sequenced, and coded. When a patient is admitted to the hospital, the condition established after study found to be chiefly responsible for occasioning the admission to the hospital should be sequenced as the principal diagnosis. The other diagnosis identified should represent all (MCC/CC) present during the admission that impact the stay. The POA indicator for all diagnoses reported must be coded correctly. Reviewers will validate for MS DRG 870, 871, and/or 872,

First Things First Planningprincipal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. Claim Type Inpatient Issue Type Complex Overpayment / Underpayment Overpayment and Underpayment Dates of Service 10/1/2007 -Open States IL, IN, KY, MI, MN, OH, WI Policy Related Links ICD-9-CM Coding Manual (for dates of service on claim)

• ICD-9-CM Addendums and coding clinics– PIM Ch 6.5.3, Section A - C - DRG Validation Review– Present on Admission Indicator Systems Implementation– OIG Report DRG 416: Septicemia, August 1989 (1)OIG Report DRG 416: Septicemia, August 1989 (1)– OIG Report DRG 416: Septicemia, August 1989 (2)

Date Approved 12/4/2009 © 2009 CGI Federal


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Principal Diagnosis - defined by UHDDS as the condition p g yestablished after study to be chiefly responsible for admission of the patient to the hospital

When Sepsis, or severe sepsis meets Principal Diagnosis definition, the following assignments are made:

1. Assign first the code for the underlying systemic infection (038.xx or 112.5 )

First Things First Planning2. Then must assign Code 995.91 Sepsis or 995.92 Severe Sepsis (Organ

Failure)3. Assign a code if applicable for any localized infections (i.e. pneumonia,

cellulitis, etc.)4. Must also code for any “ acute” organ dysfunction if you document 995.92

Secondary Diagnosis If sepsis or severe sepsis developed Secondary Diagnosis - If sepsis or severe sepsis developed after admission.

– In order to assign a code from 998.9 the term sepsis or SIRS must be documented by the physician


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Examine

ReviewQuery

Documentation Abstract

CodeIdentify

Track

Data

Compare


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1. Examine - The medical record to ensure that it is a complete record. Physician attestation statement and Discharge Summary is on the record, as well as nurses notes, treatment records and etc..

2 R iFirst Things First Planning

2. Review - Must review the Entire Medical Record to accurately assign the principal and secondary diagnosis

3. Abstract - Data from the Medical Record – Worksheet


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1. Principal diagnosis________________________________________________2. Is this the same diagnosis as the admitting diagnosis? Y N3. Presenting symptoms upon admission: (Know the Indicators)

S i i /S i /SIRS I diSepticemia/Sepsis/SIRS IndicatorsAcute mental status changesPositive blood cultureFever > 100.4 F or <97 FHeart Rate > 90BPMRespiratory Rate > 24 breats/minuteElevated WBC > 12,0000 or < 4,000Physician documentation of decreased urine output ‘ oliguria”

First Things First PlanningSevere Sepsis/Septic Shock IndicatorsThrombocytopenia PLT Count <100,000Decreased peripheral pulsesHypotension SBP < 90mmHg or SBP decrease >40mmHg Creatine > 2.0 or increase . 0.5 mg/dlCoagulation issues INR > 1.5 or PTT >60 secs.Arterial pH < 7.30

4 Ph i i d t ti d d t f di i f S i SIRS Sh k 4. Physician documentation and date of diagnosis for Sepsis, SIRS, Shock states:__________________________________________________________

5. Patient Vital signs of date of diagnosis:_________________________________6. Any applicable lab values for diagnosis: ( Check WBC’s, PLTS) TRACK DATES WHEN COMPLETED

Blood cultures result: (IF POSITIVE, LIST ORGANISM)


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7. Was the patient started on antibiotics, clotting factors, platelets, or given XIGRIS? Y N Was patient on antibiotics prior to admission? Y N

8. Does the physician document any underlying infections? Y N (Date Reported and Treatment Implemented)

9. Is there any evidence of any organ dysfunctions or failures? Y N ( Date Reported and Treatment Implemented)

10 Is there documentation to support that this organ failure is related to sepsis and if so where: ( 10. Is there documentation to support that this organ failure is related to sepsis and if so where: ( Document location in medical record)

11. Any other types of trauma, malignant neoplasm’s, or inflammation such as pancreatitis?_______________________________________________________

12. Were any devices in use and attributed to diagnosis ( i.e. Foley, VAD, tracheostomy, gastrostomy): Y N

13. Date and time if applicable of endotracheal intubation for ventilation:________________________________________________________

Was patient discharged or transferred while intubated:_____________________If applicable date and time patient was extubated:_________________________

First Things First PlanningWas ET or Tracheostomy performed in inpatient status? ____________________Date and time mechanical ventilation was initiated? _______________________Was patient weaned during time on the vent? If so hours___________________Date and time mechanical ventilation ended:_____________________________Was the patient completely weaned off the vent, and restarted within any time frame during the same admission? Yes or No, If applicable list dates______________________

Discharge status: ( Transfer MS-DRG) Home or Self Care -01Discharged/ Transferred to a Short Term General Hospital for Inpatient Care -02Discharged/ Transferred to a SNF with Medicare Certification in Anticipation of killed Care - 03Discharged/Transferred to an Intermediate Care Facility - 04Discharged/Transferred to Another Type of Health Care Facility Not elsewhere in the Code List- 05Discharged/ Transferred to Home Care- 06AMA -07Expired-20


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4. Code - Reviewer will code from data that they abstracted

5. Compare - codes that they assign to the codes that were billed

6. Identify - any areas in the medical record for areas of t i t d di i

First Things First Planninguncertainty and discrepancies

7. Track Data Collected - Highlight areas, photocopy areas in question to possibly highlight for physician

8. Query - the provider on any discrepancies found. Send them the highlighted portions of the medical record so that they can view. DO not lead .. Only identify what is in the record and ask for clarification


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• A 71 year old male with a history of COPD, DM, recent pulmonary embolism, and CHF was admitted from the emergency room after being transferred from a SNF with

Case Scenario

g y gunresponsiveness. While in the ER the patient was noted with abnormal blood gases after failing a BIPAP test.

• Subsequently he was intubated and placed on mechanical ventilation. Labs conducted in the ER revealed the patient to have a WBC 11.6, Hgb 11.7 , HCT 38.9, PLTS 330,000, Creatine0.5. Blood and sputum cultures drawn.. CXR revealed an infiltrate in the right stem bronchus. VS in ER 98.6, 112, 90/76 14.

• Patient was admitted with Acute Respiratory Failure, Pneumonia, and Probable Sepsis.

First Things First Planning• During the course of the admission the initial blood cultures taken in the ER were negative in growth. However, the sputum cultures identified H. Influenza in which was sensitive to all antibiotics, in which the patient continued on. However, the patient began to expectorate thick tenacious and copious amounts of sputum and a second set of sputum cultures on the 5th day of the stay were taken and later revealed the patient to have MRSA that was only sensitive to Vancomycin, in which was initiated.

• During the course of the admission the patient was treated with IV antibiotics for pneumonia and was later ex-tubated after the 10th day of the admission and transferred back to the SNF on oral antibiotic Levaquin. Sepsis was only mentioned at the admission and discharge.on oral antibiotic Levaquin. Sepsis was only mentioned at the admission and discharge.

• On the discharge summary the discharge diagnoses stated resolved sepsis, resolved acute respiratory failure, acute exacerbation of COPD, H. Influenza pneumonia, and MRSA resistant pneumonia.

• This record was billed at DRG 870 Septicemia or Severe Sepsis w/ + 96 hours of Mechanical Ventilation. Was this the correct MS-DRG assignment?


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• Admitted with sepsis, pneumonia, and i f ilrespiratory failure

According to AHA Coding Clinic for ICD-9-CM, a patient admitted with pneumonia and sepsis goes to sepsis as the principal diagnosis (2003, fourth quarter, pages 79-81). A patient admitted with pneumonia and respiratory failure goes to respiratory failure as the principal diagnosis (2003, second quarter, pages 21-22). When a patient is admitted with respiratory failure due to or associated with an acute nonrespiratory condition (sepsis), then the acute nonrespiratory condition is

First Things First Planning( p ), p y

sequenced as the principal diagnosis (1991, second quarter, pages 3-5). Since respiratory failure is an organ dysfunction of SIRS/sepsis, it should be listed as a secondary diagnosis. Therefore, if a patient is admitted with sepsis, pneumonia, and respiratory failure, then the sepsis will more than likely be sequenced as the principal diagnosis as it is the acute condition causing the respiratory failure. However, if the documentation specifically supports that the respiratory failure was caused by another respiratory condition and not caused by the sepsis, y p y y p ,then it may be appropriate to sequence the respiratory failure as the principal diagnosis


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• Lack of documentation to substantiate a diagnosis of septicemia/sepsis although some symptoms are present.

• Generalized septicemia/sepsis is being coded based on the physician’s diagnosis of septicemia/sepsis in the medical record; however, review of medical record documentation reveals that only a few symptoms, such as high fever and leukocytosis, are present. Coders must seek clarification f h h i i di h f i i / i h

First Things First Planningfrom the physician regarding the presence of septicemia/sepsis when only isolated symptoms are documented in the medical record and code accordingly. It should be noted that negative or inconclusive blood culture findings do not preclude a diagnosis of septicemia/sepsis in patients with clinical evidence of the condition. Coders should learn to recognize the clinical picture of septicemia/sepsis so as to be able to identify when the diagnosis of septicemia/sepsis should be questioned. See Coding Clinic, fourth quarter 2006, pages 113-116; Coding Clinic, f th t 2003 79 C di Cli i f th t 2002 fourth quarter 2003, page 79; Coding Clinic, fourth quarter 2002, page 71; Coding Clinic, second quarter 2000, page 3; Coding Clinic, fourth quarter 1988, page 10; Coding Clinic, third quarter 1988, page 12; and Coding Clinic, first quarter 1988, page 1.


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http://student.ccbcmd.edu/courses/bio141/labmanua/lab12/diseases/blood/septicemia.html

http://emedicine.medscape.com/article/786058-overview

http://www.fortherecordmag.com/archives/ftr_071204p31.shtml

http://hpmp.tmfhqi.net/LinkClick.aspx?fileticket=5vZGv%2Fbvlos%3D&tabid=521&mid=1247


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Denise Wilson RRT, RN, MISDirector, Client Education and

Performance Improvement

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• Understand how to incorporate Best Practice guidelines in appeals

• Understand how to use regulatory and

First Things First Planning• Understand how to use regulatory and

CMS guidelines to bolster the appeal argument

• What to say to an ALJy


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• Considerations for Deciding to Appeal• Considerations for Deciding to Appeal– Cost– Time– Resources

Chance of OverturnFirst Things First Planning– Chance of Overturn– Return on Investment

• In addition to:– Root Cause Analysis

Education/Remediation Plan– Education/Remediation Plan


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• Close examination of decision letter• Close examination of decision letter

– What are the instructions for appeal?

– What forms do I need?

First Things First Planning– Where do I send my appeal?– What was the issue?

• Create Appeal Letter Templatespp p


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Building the Foundation


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CGI Federal RACB IssuesCGI Federal RACB Issues

• http://racb.cgi.com/Issues.aspx

• ICD‐9‐CM Coding Manual (for dates of service on claim)• ICD‐9‐CM Addendums and coding clinics

First Things First Planning• PIM Ch 6.5.3, Section A ‐ C ‐ DRG Validation Review• Present on Admission Indicator Systems Implementation• OIG Report DRG 416: Septicemia, August 1989 (1)• OIG Report DRG 416: Septicemia, August 1989 (2)

• Date Approved 12/4/2009 pp / /


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• Paint the Picture• Paint the Picture– Comorbidities and Complications (CC or

MCC)– Medical Complexity

P id R d MFirst Things First Planning

• Provide a Road Map– Where is the Documentation?

• Write to the ALJ– Best chance of overturnBest chance of overturn


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• Use the Best Evidence• Use the Best Evidence– CMS Internet Only Manuals (IOM)– National Coverage Determinations; Local

Coverage Determinations – ICD-9-CM Official Coding Guidelines

C di Cli i

First Things First Planning– Coding Clinics– Code of Federal Regulations (CFR)– Social Security Act– Evidence Based Guidelines, Position

Statements, Expert Opinions from National Medical AssociationsMedical Associations


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• O'Grady NP, et.al., American College of Critical Care Medicine, Infectious Diseases Society of America. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care yMed 2008 Apr;36(4):1330‐49.

• Dellinger RP, et. al., Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 2008 Jan;34(1):17‐60. [341 f ]references]


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• Mark Forshag, MD, FCCP. “New Treatments for Sepsis.” American College of Chest Physicians. http://www.chestnet.org/education/online/pccu/vol17/lessons15_16/lesson15.php (accessed December 30, 2009).

• Deborah Hale “Coding corner Is it sepsis?” ACP HospitalistDeborah Hale. Coding corner Is it sepsis? ACP Hospitalist, February 2009. http://www.acphospitalist.org/archives/2009/02/coding.htm

• Gregory A Schmidt, MD, Jess Mandel, MD, Polly E Parsons, MD, Daniel J Sexton, MD, Kevin C Wilson, MD. “Management of severe sepsis and septic shock in adults.” (Last updated October 16, 2009). www.uptodate.com


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• Gregory A Schmidt, MD, Jess Mandel, MD, Polly E Parsons, MD, Daniel J Sexton, MD, Kevin C Wilson, MD. “Management of severe sepsis and septic shock in adults.” (Last updated October 16, 2009). www.uptodate.com

• Surviving Sepsis Campaign Facts 2009Surviving Sepsis Campaign Facts, 2009. http://www.survivingsepsis.org/About_the_Campaign/Pages/default.aspx. (Accessed December 30, 2009).

• Steven M. Hollenberg, MD, et. Al., “Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update.” Critical Care Medicine. 2004 September; 32(9):1928‐1948.


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42 CFR §§405 900 through 405 106442 CFR §§405.900 through 405.1064• ALJ Review Authority

– Jurisdiction– Scope of Review

• § 405 1062 Applicability of local coverage

First Things First Planning§ 405.1062 Applicability of local coverage determinations and other policies not binding on the ALJ and MAC (Medicare Appeals Council).

– (a) ALJs and the MAC are not bound by LCDs, LMRPs, or CMS program guidance, such as program memoranda and manual instructions, but will give substantial , gdeference to these policies if they are applicable to a particular case.


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20 CFR 416 927: Evaluating Opinion 20 CFR 416.927: Evaluating Opinion Evidence

• Examining Relationship• Treatment Relationship

– Length and Frequency

First Things First Planningg q y

– Nature and Extent

• Supportability– Objective and Subjective Findings

• Medical Signs and Laboratory Results


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• Include an Attachments List• Include an Attachments List

• Include all Attachments – Electronic Copy

First Things First Planning• Use a Document Editor to Highlight the Medical Record

• Send all Communication via a Traceable Method


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Next Session:Wednesday, June 23


1:00PM EST

Respiratory Failure with Ventilator Supportwith Ventilator Support

For more information or to view upcoming Webinar events, visit Intersecthealthcare.com

septicemia/sepsis slides

Health & Medicine

severe sepsis sepsis

firstthingsfirstplanning

sepsis infectious

conditions c

independent cause sepsis

diagnosis of sirs

chest intensive care

infection bone rc