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Sepsis
New 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...
790.7 Bacteremia
 Presence of bacteria in the blood
 Use additional code to identify organism (041)
 Excludes
 Bactere...
038.x Septicemia
Infectious diseases due to the accumulation
and persistence of bacteria and/or their toxins
in the blood ...
Septicemia and Sepsis
 Septicemia and Sepsis are no longer
synonymous terms
AHA Coding Clinic for ICD-9-CM, Fourth
Quarte...
Coding “Sepsis”
 Sepsis requires two codes
Underlying condition 038.x
and
995.91 or 995.92
Per Instructional notes in Tab...
995.9x SIRS
 Systemic Inflammatory Response Syndrome
 A major complication of infection and/or
trauma that includes syst...
995.9x SIRS
 Two or more of the following:
 Temperature >38 C or <36 C
 Heart Rate > 90 beats per minute
 Respiratory ...
Source: Bone et al.Source: Bone et al. ChestChest 1992;101:16441992;101:1644
SIRS Continuum
SIRSINFECTION
PANCREATITIS
BUR...
995.9x SIRS
 995.90 SIRS, unspecified
 995.91 … due to infectious process. Sepsis
 995.92 … due to infectious process w...
995.9x SIRS sequencing
 Code first the underlying cause
 Use an infection or trauma code plus 995.9x
(SIRS) to accuratel...
995.92 and 995.94
 In presence of organ dysfunction use
additional code to specify the organ
dysfunction, e.g.:
 Acute r...
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 (...
Mortality
Septic
Shock
53-63%
20-53%Severe Sepsis
300,000
7-17%
Sepsis
400,000
Incidence
Source: Balk, R.A. Crit Care Clin...
SIRS Therapies – Procedure Codes
 00.11 Infusion Of Drotrecogin Alfa (Activated)
 Infusion of recombinant protein Xigris...
V09.x Resistance to Microorganisms
 Drug Resistant Organisms
 Resistance to Methicillin V09.0
 Other common drug resist...
Example: Bacteremia
 Bacteremia (cause unknown)
 Blood cultures growing E coli per MD
documentation
790.7 Bacteremia
041...
Example: Bacteremia
 Bacteremia associated with/due to urinary
tract infection
599.0 UTI
790.7 Bacteremia
790.7 is from C...
Example: Streptococcal
Septicemia/Sepsis
 Streptococcal Septicemia
(documented as septicemia)
038.0
 Streptococcal Sepsi...
Example: SIRS
 SIRS due to 3rd degree burns and trauma
942.39 Third degree burn, trunk
808.43 Pelvic fracture
995.93 SIRS...
Example: SIRS
 SIRS due to acute pancreatitis
577.0 Acute Pancreatitis
995.93 SIRS (no-infection, without organ
dysfuncti...
Example: SIRS
 Acute pancreatitis with SIRS and hepatorenal
syndrome
577.0 Acute pancreatitis
995.94 SIRS (no infection, ...
Example: SIRS
 A patient with chronic renal failure on
chronic dialysis admitted for treatment of
gram negative sepsis
03...
Example: Septic Shock
 A patient is discharged with the diagnosis of
MRSA Septicemia with septic shock.
038.11 MRSA Septi...
Not covered in Coding Clinic (yet):
 A patient is admitted to the hospital in respiratory failure
due to pseudomonas pneu...
Not covered in Coding Clinic (yet):
Patient admitted with Respiratory Failure due to
Aspiration Pneumonia and SIRS (severe...
Not covered in Coding Clinic (yet):
 Line Sepsis
 996.62, 038.9, 995.91
OR
 038.9, 995.91, 996.62 ?
Based on previous g...
What can you do?
 Why does it getting it right matter?
 Severity of illness
 Statistics
 Reimbursement
 What can you ...
Questions?
 Barry Libman, RHIA, CCS, CCS-P
Barry Libman Inc.
978-369-7180
blibman@barrylibmaninc.com
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Sepsis New Guidelines, New Codes

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  • This conceptual framework shows the interrelationships between infection, non-infectious disorders, SIRS, sepsis and severe sepsis. Components of the process not discussed on the following slides include:
    Infection: a microbial phenomenon characterized by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by those organisms
    Bacteremia: the presence of viable bacteria in the bloodstream
    Septic shock: sepsis-induced hypotension despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria or an acute alteration in mental status
    Multiple organ dysfunction syndrome (MODS): presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention
    Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992;101:1644-55.
    Opal SM, Thijs L, Cavaillon JM, et al. Relationships between coagulation and inflammatory processes. Crit Care Med 2000;28:S81-2.
  • Transcript of "Sepsis New Guidelines, New Codes "

    1. 1. Sepsis New Guidelines, New Codes Barry Libman, RHIA, CCS, CCS-P President Barry Libman Inc.
    2. 2. 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
    3. 3. 790.7 Bacteremia  Presence of bacteria in the blood  Use additional code to identify organism (041)  Excludes  Bacteremia of newborn (771.83)
    4. 4. 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)
    5. 5. Septicemia and Sepsis  Septicemia and Sepsis are no longer synonymous terms AHA Coding Clinic for ICD-9-CM, Fourth Quarter, 2003
    6. 6. Coding “Sepsis”  Sepsis requires two codes Underlying condition 038.x and 995.91 or 995.92 Per Instructional notes in Tabular Index.
    7. 7. 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.
    8. 8. 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
    9. 9. Source: Bone et al.Source: Bone et al. ChestChest 1992;101:16441992;101:1644 SIRS Continuum SIRSINFECTION PANCREATITIS BURNS TRAUMA OTHER SEPSIS SEVERE SEPSIS SEPTIC SHOCK
    10. 10. 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
    11. 11. 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
    12. 12. 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)
    13. 13. 995.9x SIRS sequencing  Sequence 1. underlying condition 2. SIRS 995.9x 3. any organ dysfunction
    14. 14. 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)
    15. 15. Mortality Septic Shock 53-63% 20-53%Severe Sepsis 300,000 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
    16. 16. 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
    17. 17. V09.x Resistance to Microorganisms  Drug Resistant Organisms  Resistance to Methicillin V09.0  Other common drug resistance?
    18. 18. Example: Bacteremia  Bacteremia (cause unknown)  Blood cultures growing E coli per MD documentation 790.7 Bacteremia 041.4 E coli organism
    19. 19. 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
    20. 20. Example: Streptococcal Septicemia/Sepsis  Streptococcal Septicemia (documented as septicemia) 038.0  Streptococcal Sepsis (SIRS and documented infection) 038.0 995.91
    21. 21. 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)
    22. 22. Example: SIRS  SIRS due to acute pancreatitis 577.0 Acute Pancreatitis 995.93 SIRS (no-infection, without organ dysfunction)
    23. 23. 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
    24. 24. 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
    25. 25. 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)
    26. 26. 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
    27. 27. 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)
    28. 28. 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.
    29. 29. 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
    30. 30. Questions?  Barry Libman, RHIA, CCS, CCS-P Barry Libman Inc. 978-369-7180 blibman@barrylibmaninc.com
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