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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

  • 1. Sepsis New Guidelines, New Codes Barry Libman, RHIA, CCS, CCS-P President Barry Libman Inc.
  • 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. 790.7 Bacteremia
    • Presence of bacteria in the blood
    • Use additional code to identify organism (041)
    • Excludes
      • Bacteremia of newborn (771.83)
  • 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. Septicemia and Sepsis
    • Septicemia and Sepsis are no longer synonymous terms
    • AHA Coding Clinic for ICD-9-CM, Fourth Quarter, 2003
  • 6. Coding “Sepsis”
    • Sepsis requires two codes
    • Underlying condition 038.x
    • and
    • 995.91 or 995.92
    • Per Instructional notes in Tabular Index.
  • 7. 995.9x SIRS
    • S ystemic I nflammatory R esponse S yndrome
    • 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. 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. SIRS Continuum Source: Bone et al. Chest 1992;101:1644 SIRS INFECTION PANCREATITIS BURNS TRAUMA OTHER SEPSIS SEVERE SEPSIS SEPTIC SHOCK
  • 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. 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. 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. 995.9x SIRS sequencing
    • Sequence
    • 1. underlying condition
    • 2. SIRS 995.9x
    • 3. any organ dysfunction
  • 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. Mortality Increases in Septic Shock Patients Mortality Incidence Source: Balk, R.A. Crit Care Clin 2000;337:52 Approximately 200,000 patients including 70,000 Medicare patients have septic shock annually Septic Shock 53-63% 20-53% Severe Sepsis 300,000 7-17% Sepsis 400,000
  • 16. SIRS Therapies – Procedure Codes
    • 00.11 Infusion Of Drotrecogin Alfa (Activated)
      • Infusion of recombinant protein Xigris TM
      • 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 Zyvox TM
  • 17. V09.x Resistance to Microorganisms
    • Drug Resistant Organisms
    • Resistance to Methicillin  V09.0
    • Other common drug resistance?
  • 18. Example: Bacteremia
    • Bacteremia (cause unknown)
    • Blood cultures growing E coli per MD documentation
    • 790.7 Bacteremia
    • 041.4 E coli organism
  • 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. Example: Streptococcal Septicemia/Sepsis
    • Streptococcal Septicemia
    • (documented as septicemia)
    • 038.0
    • Streptococcal Sepsis
    • (SIRS and documented infection)
    • 038.0
    • 995.91
  • 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. Example: SIRS
    • SIRS due to acute pancreatitis
    • 577.0 Acute Pancreatitis
    • 995.93 SIRS (no-infection, without organ dysfunction)
  • 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. 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. 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. 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 Zyvox TM .
    • 518.81 Respiratory Failure
    • 482.1 Pseudomonas pneumonia
    • 038.43 Pseudomonas sepsis
    • 995.91 SIRS (infection, no organ dysfunction)
    • 00.14 Zyvox TM Infusion
  • 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. 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. 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. Questions?
    • Barry Libman, RHIA, CCS, CCS-P
    • Barry Libman Inc.
    • 978-369-7180
    • [email_address]