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Sepsis: Understand clinical presentation and coding strategies for ICD-10

JustCoding News: Inpatient, November 18, 2015

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 A 12-year-old male developed umbilical discomfort Monday and didn't eat much dinner. On Tuesday, he started vomiting at school and the pain shifted to his right lower quadrant. His parents brought him to the ED, where his vital signs showed:

  • Temperature of 102.4
  • Pulse rate of 100
  • Respiration of 16 breaths per minute
  • White blood cell count of 18,000 
The physician's exam showed localized tenderness with rebound in the right lower quadrant with rectal tenderness referred to the right lower quadrant.
The surgeon diagnosed acute appendicitis and prescribed a dose of Levaquin IV. The surgeon then took the patient to the operating room Tuesday and removed a purulent, non-perforated appendix. The patient ate well on Wednesday and was discharged home on no antibiotics. He returned to school three days after discharge.
Did this patient have sepsis, defined as systemic inflammatory response syndrome (SIRS) plus infection?
The answer is no, says Robert S. Gold, MD, founder and CEO of DCBA, Inc., in Atlanta.
"The patient certainly had acute intra-abdominal infection, fever, and elevated white blood cell count, so an infection and two of the four criteria of SIRS," Gold says. The patient was not started on a "sepsis bundle" but was given a dose of antibiotic preoperatively; he was discharged 24 hours after surgery with no antibiotics.
To correctly code for sepsis, coding professionals also need to understand the clinical presentation of sepsis. 
Defining sepsis
SIRS generally refers to the systemic response to an inflammatory process, such as infection, trauma/burns, or other insult, with symptoms including but not limited to:
  • Fever
  • Tachycardia
  • Tachypnea
  • Leukocytosis 
These are only symptoms and lab abnormalities unless the physician determines their presence is due to the body's response to an infectious or noninfectious source of inflammation, Gold says. Any other grouping of these abnormalities for a reason other than a response to an inflammatory insult does not represent SIRS—just abnormal readings.
Tachycardia caused by atrial fibrillation with rapid ventricular response is not caused by an infection.
Leukocytosis caused by steroids or by leukemia is not caused by an infection.
Tachypnea caused by asthma is not caused by an infection.
Hypotension caused by dehydration with hypovolemia or by beta blockers is not caused by an infection.
“Be aware of infections normally associated with fever and elevated white count and, if the patient is not particularly sick, do not seek documentation of sepsis,” Gold says.
Abdominal infections such as acute appendicitis, acute diverticulitis, and acute cholecystitis always have fever and elevated white blood cell count; they also may have tachycardia and tachypnea due to stress. That doesn't mean the patient is septic.
“We have to take a look at each of the abnormalities that might be identified in the emergency room, the physician's office, or on the unit to be sure that the criteria that are seen are caused by an infection or an inflammatory process,” Gold says.
Other infections such as bacterial pneumonias, acute otitis media, acute cellulitis, and perirectal abscesses always have fever and elevated white blood cell count. The patient may have tachycardia and tachypnea due to stress or to hypoxia in cases of pneumonia, Gold says. Again, the patient doesn't always have sepsis. “These are not necessarily indicative that the patient has sepsis, so we need to be very careful,” he says.
In addition, all of the abnormalities seen and associated with sepsis can exist unrelated to sepsis or an inflammatory process, Gold says. 
Coding sepsis in ICD-10-CM
Coding professionals will see some changes in how they report sepsis in ICD-10-CM. The first thing they absolutely must do is read the ICD-10-CM Official Guidelines for Coding and Reporting, says Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, an AHIMA-approved ICD-10-CM/PCS trainer with more than 30 years of experience in HIM.
Coding professionals also need to review the chapter-specific guidelines, Bryant adds.
“For coding sepsis in ICD-10, the tabular tells us that for the A41 range we code first the postprocedural sepsis,” she says.
Coding professionals should also read the Excludes1 note, meaning “not coded here,” Bryant adds. This note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 note is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
For example, under A40 (Streptococcal sepsis), the Excludes1 note covers:
  • Neonatal (P36.0-P36.1)
  • Puerperal sepsis (O85)
  • Sepsis due to Streptococcus, group D (A41.81) 
An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.
Coding professionals should also be aware of the code first note under A40, which instructs them to code first:
  • Postprocedural streptococcal sepsis (T81.4)
  • Streptococcal sepsis during labor (O75.3)
  • Streptococcal sepsis following abortion or ectopic or molar pregnancy (O03?O07, O08.0)
  • Streptococcal sepsis following immunization (T88.0)
  • Streptococcal sepsis following infusion, transfusion, or therapeutic injection (T80.2-) 
ICD-10-CM sepsis guidelines
For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9 (sepsis, unspecified organism).
A code from subcategory R65.2 (severe sepsis) should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented.
If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2 (severe sepsis). An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider, Bryant says.
Coding professionals also should note that ICD-10-CM does not include the term “urosepsis,” says Bryant. If a physician documents urosepsis, coding professionals or CDI specialists will need to query. 
Severe sepsis
Severe sepsis generally refers to sepsis with associated acute organ dysfunction.
Clinical presentations can vary depending on the original site of the infection, but they can also be nonspecific, Gold says. “You can have sepsis, and you know that the patient has sepsis, but you may never find the infection of origin. Or you may have systemic inflammatory response without sepsis because the SIRS is due to something else.”
If the physician documents severe sepsis, coding professionals will need to report two codes, Bryant says. They should first code the underlying systemic infection, then report a code from subcategory R65.2 (severe sepsis).
If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction, follow the instructions for coding severe sepsis, Bryant says.
If severe sepsis is present on admission (POA), and meets the definition of principal diagnosis, coding professionals should assign the code for the underlying systemic infection as principal diagnosis followed by the appropriate code from subcategory R65.2, Bryant say". “A code from subcategory R65.2 can never be assigned as a principal diagnosis.”
When severe sepsis is not POA but develops during the encounter, both the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as secondary diagnoses.
If the documentation is not clear whether severe sepsis was POA, query the provider, Bryant says.
Strategies for coding improvement
Coding professionals should work with physicians to differentiate between SIRS and symptoms that look like SIRS, Bryant says. Physicians have been trained to document SIRS if abnormalities are present. Some of that training comes from CDI specialists and queries, she adds. 
“Because sepsis has been defined as an inflammatory response to an infection, we need to clearly identify the abnormalities that are inherent in them because they could create overcoding or overdocumenting,” Bryant says. “We need to use caution and not make assumptions. Querying is the best practice.” 
Editor's note: For more information on how to code for sepsis, see the HCPro on-demand webcast, “Prepare for Sepsis Documentation and Coding in ICD-10-CM." This article was originally published in the October issue of Briefings on Coding Compliance Strategies. Email your questions to editor Steven Andrews at sandrews@hcpro.com

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