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Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
Septicemia/Sepsis Slides
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Septicemia/Sepsis Slides

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Septicemia/Sepsis Workshop …

Septicemia/Sepsis Workshop
(MS-DRG’s 870, 871-872)

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  • 1. Documentation, Coding Audit, and Appeal Workshops Sponsored by Intersect Healthcare Inc. Healthcare, Inc Part One: Septicemia/Sepsis Workshop (MS DRG s (MS-DRG’s 870, 871-872) 871 872) Next Session: Wednesday, June 23 1:00PM 1 00PM EST Respiratory Failure with Ventilator Support 1
  • 2. Documentation, Coding Audit, and Appeal Workshops Sponsored by Intersect Healthcare Inc. Healthcare, Inc Part One: Septicemia/Sepsis Workshop (MS-DRG’s 870 871 872) (MS DRG’ 870, 871-872) Your Panel: Joel Moorhead, MD, PhD 1:00-1:30 pm Documenting Septicemia/Severe Sepsis Charmira Johnson, CCS, BS, LPN, CCDS 1:30-2:00 pm Coding/Audits for Septicemia/Severe Sepsis Denise Wilson, RN, RRT, MS 2:00-2:30 pm Appealing Septicemia/Severe Sepsis Takebacks 2
  • 3. Joel Moorhead, MD, PhD Adjunct Associate Professor Rollins School of Public Health Emory University Atlanta, GA 3
  • 4. • 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 4
  • 5. • Inflammation is body’s NORMAL response body s to infection, chemical exposure, or trauma – Stage I: Initiation of inflammatory response p • WBCs secrete proteins (cytokines) that promote First Things First Planning 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 (c) 2010 Intersect Healthcare, Inc. 5 5
  • 6. – Inflammation Stage III • Body loses control • Homeostasis cannot be restored • Cytokine activity becomes destructive – Capillaries damaged – Multiple organs may be damaged » Bone RC. Critical Care Medicine 1996;24:163-172 First Things First Planning (c) 2010 Intersect Healthcare, Inc. 6 6
  • 7. • Age >65 Age >65 • Immunosuppression – Steroids, chemotherapy, immunosuppressant drugs – AIDS and other chronic immunological disorders • Alcohol abuse • Malnutrition • First Things First Planning Invasive instrumentation • Persistent inflammatory or infectious focus • Chronic disease, e.g. COPD, DM, CAD, renal  failure f il • Kohl BA and Deutschman CS. Current Opinion in Critical Care 2006;12:325‐332 (c) 2010 Intersect Healthcare, Inc. 7 7
  • 8. • Infection – Inflammatory response caused by microorganisms • Bacteremia – Bacteria in the blood • SIRS First Things First Planningof – Inflammatory response, independent cause • Sepsis – SIRS arising from infection – Bone RC et al. Chest 1992;101:1644-1655 (c) 2010 Intersect Healthcare, Inc. 8 8
  • 9. • 995 9 Systemic Inflammatory 995.9 Response Syndrome (SIRS) – 995.91 Sepsis • SIRS due to infectious process without acute organ dysfunction – 995.92 Severe sepsis • Sepsis with acute organ dysfunction First Things First Planning • 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 (c) 2010 Intersect Healthcare, Inc. 9 9
  • 10. • ACCP/SCCM Consensus Conference (1991) • SCCM/ESICM/ACCP/ATS/SIS Consensus Conference (2001) – ACCP: American College of Chest Physicians – SCCM: Society of Critical Care Medicine First Things First Planning – ESICM: European Society of Intensive Care Medicine – ATS: American Thoracic Society – SIS: Surgical Infection Society (c) 2010 Intersect Healthcare, Inc. Copyright 2009 5 10 10
  • 11. 1991 ACCP/SCCM 2001 ACCP/SCCM…Update • Infection with at least • Infection documented or two of the following, suspected and “some of ” … not due to other – General parameters cause: • Temp >38.3° C or <36 ° C – Temp >38° C or <36 ° C • HR >90 or 2 SD > age mean • >100.4° F or <96.8 ° F • RR >30 per minute – HR >90 per minute – Inflammatory parameters – Hyperventilation • WBC >12,000 or <4000 /μL – RR >20 per minute • Or >10% bands – PaCO2 <32 mm Hg – Hemodynamic parameters – WBC >12,000 or <4000 /μL – Tissue perfusion parameters – Levy MM et al for the International • Or >10% bands Sepsis Definitions conference. – Bone RC et. al., Chest Intensive Care Medicine 2003;29:530- 1992;101:1644-1655 538 (c) 2010 Intersect Healthcare, Inc. 11 11
  • 12. • 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 • Altered mental status Alt d t l t t • First Things First Planning 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 (c) 2010 Intersect Healthcare, Inc. 12 12
  • 13. • Leukocytosis (WBC >12,000/ /μL) • Leukopenia (WBC <4000 /μL) • Normal WBC with >10% immature forms – Usually reported as “Bands” • Plasma C reactive protein >2 SD above normal • First Things First Planning Plasma procalcitonin >2 SD above normal – Levy MM et al for the International Sepsis Definitions conference. Intensive Care Medicine 2003;29:530-538 (c) 2010 Intersect Healthcare, Inc. 13 13
  • 14. • 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 Planning 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) <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 (c) 2010 Intersect Healthcare, Inc. 14 14
  • 15. • Hyperlactatemia (>3 mmol/l) • Decreased capillary refill or mottling • Levy MM et al for the International Sepsis Definitions conference. Intensive Care Medicine 2003;29:530-538 2003;29:530 538 (c) 2010 Intersect Healthcare, Inc. 15 15
  • 16. • 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 Planning • 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 (c) 2010 Intersect Healthcare, Inc. Copyright 2009 5 16 16
  • 17. • 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 Planning 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: 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 (c) 2010 Intersect Healthcare, Inc. Copyright 2009 5 17 17
  • 18. • History of chronic organ insufficiency or immunocompromise? • Acute renal failure? • Age • Vital signs – Temperature, HR, RR • First Things First Planning Lab values – pH, sodium, potassium, creatinine, hematocrit, WBC, PaO2, alveolar-arterial O2 gradient • Apache II score 21-25: Predicted mortality 50%; 26-30: 70% – Patients with sepsis may have higher-than-predicted mortality – Lee KH et al. Singapore Med J 1993;34:41-44 (c) 2010 Intersect Healthcare, Inc. 18 18
  • 19. Organ System Sign of Dysfunction • Cardiovascular • ↑HR, ↓ BP, edema ↓ capillary refill, skin mottling • Pulmonary P l • Tachypnea, hypoxemia • Renal • ↑ Creatinine, oliguria • Hepatic • Hyperbilirubinemia • Gastrointestinal • Ileus – Based on Levy MM et al for the International Sepsis Definitions conference. Intensive Care Medicine 2003;29:530-538 (c) 2010 Intersect Healthcare, Inc. 19 19
  • 20. Organ System Sign of Dysfunction • Neurological • Altered mental status • Hematologic • Leukocytosis, leukopenia, >10% bands, thrombocytopenia, coagulopathy • General and Metabolic • 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 (c) 2010 Intersect Healthcare, Inc. 20 20
  • 21. • 995.92 S 99 92 Severe S Sepsis i • Acute kid kidney injury i j and • Acute respiratory failure • 995.94 SIRS due to • Critical illness non-infectious process myopathy with acute organ • Critical illness dysfunction polyneuropathy l th – Code first underlying infection • Disseminated – Use additional code to intravascular specify acute organ coagulopathy syndrome dysfunction, such as … • Encephalopathy • Hepatic failure H ti f il (c) 2010 Intersect Healthcare, Inc. 21 21
  • 22. • 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 Planning • 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 995.94 d t i f ti ith acute organ dysfunction (c) 2010 Intersect Healthcare, Inc. 22 22
  • 23. • Lab tests f b favoring i • Non-infectious condition → N i f ti diti infection that results in SIRS, infectious SIRS (probably little help for coding) see Section 1.C.17.b.12. – ICD-9 Official Guidelines for Coding and – ↑ C-reactive protein Reporting, Section 1.C.17.g – ↑ Procalcitonin (cytokine) • If sepsis meets definition of – ↓ Eosinophil count principal diagnosis, sequence septicemia before the non- non infectious condition • Only an issue if both • When both the non-infectious infectious and condition and the infectious condition (sepsis) meet the noninfectious causes definition of principal are present in same diagnosis, either can be patient assigned as principal diagnosis. – ICD-9 Official Guidelines for Coding and Reporting, Section 1.C.1.b.12. (c) 2010 Intersect Healthcare, Inc. 23 23
  • 24. • Trauma • Surgery – Kohl BA, Deutschman CS. klCurr Opin Crit • Pancreatitis Care 2006;12:325-332 • Ischemia • Medications – Coding Clinic 1st Quarter 2010, pages 10-11 • Hemorrhagic shock • Malignant neoplasm • Immune-mediated • Other types of organ injury inflammatory • Bone RC. JAMA 1992;268(24):3452- 3455 conditions – Coding Clinic 1st Quarter 2010, page 10 (c) 2010 Intersect Healthcare, Inc. 24 24
  • 25. • Aspiration • Autoimmune Pneumonia (507.0) P i (507 0) diseases di indexed under – Systemic lupus – Rheumatoid arthritis Category 507 – Sarcoidosis Pneumonitis due to solids and liquids q • Associated – No infectious examples conditions diti – Liver – Aspiration + infection? • Hepatitis • If aspiration led to infectious • Primary biliary cirrhosis pneumonia after admission, the infectious condition was – Kidney not present on admission and • Nephritis was not eligible for principal • Glomerulonephritis diagnosis. diagnosis – GI • Crohn’s disease • Ulcerative colitis (c) 2010 Intersect Health care, Inc. 25 25
  • 26. • Risk factors • Clinical syndrome – Prolonged rupture of – Signs of circulatory g y membranes compromise in first month of life – Pre-term labor • Pallor, poor perfusion – Maternal fever • Hypotonia – Unhygienic postnatal • Poor responsiveness care – Low birth weight • PDx 771.81 Septicemia of – Feeding of newborn (not 038.xx) contaminated foods – 041.xx Bacterial infection and fluids – If applicable … • 995.92 Severe sepsis • Acute organ dysfunction code – Edmond K, Zaidi A. PLoS Medicine 2010;7(3):e1000213 (c) 2010 Intersect Healthcare, Inc. 26 26
  • 27. SIRS SEPSIS • Antibiotics when • Broad-spectrum antibiotics – Immunocompromised • Crystalloid, vasopressors – Hemodynamically – Hypotension unstable – Infection suspected • Low-dose steroids for septic shock • IV fl id vasopressors fluids, – Hypotension • Control blood glucose levels • Treatment of • Treatment of complications complications • Drotrecogin alfa (Xigris®) • Control of blood – Recombinant protein C glucose levels – Anti thrombotic Anti-thrombotic – Anti-inflammatory • Oxygen – Used when risk of mortality • Burdette SD, Parilo MA. Emedicine.medscape.com/article/ high 168943-print (c) 2010 Intersect Healthcare, Inc. 27 27
  • 28. • 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 Planning – 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 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 (c) 2010 Intersect Healthcare, Inc. Copyright 2009 5 28 28
  • 29. • If the patient isn’t really sick, he or she probably isn’t i ’ septic. i – 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 infectious or a non-infectious process. • First Things First Planning 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. (c) 2010 Intersect Healthcare, Inc. Copyright 2009 5 29 29
  • 30. (c) 2010 Intersect Healthcare, Inc. 30 30
  • 31. Charmira Orr, BS, LPN, CCS, CPC, CCDS Director of Coding and Audit Services Intersect Healthcare, Inc. , 31
  • 32. • Understand how to apply the ICD-9 CM coding and sequencing guidelines to assign related codes for Septicemia, SIRS, and Sepsis • The RAC, Septicemia, and Severe Sepsis First Things First Planning • Auditing the Medical Record for Septicemia, SIRS, and Sepsis documented diagnosis (c) 2010 Intersect Healthcare, Inc. 32 32
  • 33. • 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 054.5 Septicemia 022.3 also MCC Conditions • First Things First Planning 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 (c) 2010 Intersect Healthcare, Inc. 33 33
  • 34. DRG RW GMLOS DRG 791 Prematurity  y RW 3.2039 GMLOS 0.0 with Major Problems MS‐DRG 974 HIV  RW 2.5656 GMLOS 7.3 with Major Related  Conditions with a  MCC MS‐DRG 870  RW 5.7258 GMLOS 12.9 Septicemia or Severe  Sepsis with h Mechanical  Ventilation 96+ Hours MS‐DRG 871 RW 1.8222 GMLOS 5.5 Septicemia or Severe  Sepsis w/o  Mechanical  Ventilation 96 +  Hours with MCC MS‐DRG 872  RW 1.1209 GMLOS 4.7 Septicemia or Severe  Sepsis w/o  Mechanical  Ventilation 96+ hours  w/o MCC  (c) 2010 Intersect Healthcare, Inc. 34 34
  • 35. • Systemic Inflammatory Response Syndrome • DEF: As a “acute” clinical response to an infection insult acute 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 within the medical record • First Things First Planning 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 (c) 2010 Intersect Healthcare, Inc. 35 35
  • 36. (c) 2010 Intersect Healthcare, Inc. 36 36
  • 37. Infection SIRS SEPSIS (c) 2010 Intersect Healthcare, Inc. 37 37
  • 38. • 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 ICD 9 Code 995 91 excludes 995.90 SIRS, NOS 995.91 995 90 SIRS • • First Things First Planning 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 (c) 2010 Intersect Healthcare, Inc. 38 38
  • 39. • Severe Sepsis includes the same definitive data Sepsis- 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 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 (c) 2010 Intersect Healthcare, Inc. 39 39
  • 40. • Issue Details Name Septicemia DRG 416, 576 MS-DRG 870, 871, 872 (At this time, MS DRG 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, principal diagnosis, secondary diagnosis, and procedures affecting or potentially First Things First Planning 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 (2) Date Approved 12/4/2009 © 2009 CGI Federal (c) 2010 Intersect Healthcare, Inc. 40 40
  • 41. Principal Diagnosis - defined by UHDDS as the condition p g y established 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 ) 2. Then must assign Code 995.91 Sepsis or 995.92 Severe Sepsis (Organ 3. First Things First Planning Failure) 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 after admission. – In order to assign a code from 998.9 the term sepsis or SIRS must be documented by the physician (c) 2010 Intersect Healthcare, Inc. 41 41
  • 42. Examine Query Review Track Documentation Abstract Data Identify Code Compare (c) 2010 Intersect Healthcare, Inc. 42 42
  • 43. 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. Review - Must review the Entire Medical Record to 2 R i First Things First Planning accurately assign the principal and secondary diagnosis 3. Abstract - Data from the Medical Record – Worksheet (c) 2010 Intersect Healthcare, Inc. 43 43
  • 44. 1. Principal diagnosis________________________________________________ 2. Is this the same diagnosis as the admitting diagnosis? Y N 3. Presenting symptoms upon admission: (Know the Indicators) Septicemia/Sepsis/SIRS I di S i i /S i /SIRS Indicators Acute mental status changes Positive blood culture Fever > 100.4 F or <97 F Heart Rate > 90BPM Respiratory Rate > 24 breats/minute Elevated WBC > 12,0000 or < 4,000 Physician documentation of decreased urine output ‘ oliguria” Severe Sepsis/Septic Shock Indicators First Things First Planning Thrombocytopenia PLT Count <100,000 Decreased peripheral pulses Hypotension SBP < 90mmHg or SBP decrease >40mmHg Creatine > 2.0 or increase . 0.5 mg/dl Coagulation issues INR > 1.5 or PTT >60 secs. Arterial pH < 7.30 4. 4 Physician documentation and date of diagnosis for Sepsis, SIRS, Shock Ph i i d t ti dd t f di i f S i SIRS Sh k 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) (c) 2010 Intersect Healthcare, Inc. 44 44
  • 45. 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. 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:_________________________ Was ET or Tracheostomy performed in inpatient status? ____________________ First Things First Planning 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 -01 Discharged/ Transferred to a Short Term General Hospital for Inpatient Care -02 Discharged/ Transferred to a SNF with Medicare Certification in Anticipation of killed Care - 03 Discharged/Transferred to an Intermediate Care Facility - 04 Discharged/Transferred to Another Type of Health Care Facility Not elsewhere in the Code List- 05 Discharged/ Transferred to Home Care- 06 AMA -07 Expired-20 (c) 2010 Intersect Healthcare, Inc. 45 45
  • 46. 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 uncertainty and di t i t d discrepancies i First Things First Planning 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 (c) 2010 Intersect Healthcare, Inc. 46 46
  • 47. Case Scenario • 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 g y g unresponsiveness. 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, Creatine 0.5. 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. During the course of the admission the initial blood cultures taken in the ER were negative in First Things First Planning • 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 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? (c) 2010 Intersect Healthcare, Inc. 47 47
  • 48. • Admitted with sepsis, pneumonia, and respiratory failure i f il 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 ( p ), p y sequenced as the principal diagnosis (1991, second quarter, pages 3- First Things First Planning 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 (c) 2010 Intersect Healthcare, Inc. 48 48
  • 49. • 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 from the physician regarding the presence of septicemia/sepsis when f h h i i di h f i i / i h First Things First Planning 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, fourth quarter 2003 page 79; Coding Clinic, fourth quarter 2002, page f th t 2003, 79 C di Cli i f th t 2002 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. (c) 2010 Intersect Healthcare, Inc. 49 49
  • 50. 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.sh tml http://hpmp.tmfhqi.net/LinkClick.aspx?fileticket=5vZGv%2Fb vlos%3D&tabid=521&mid=1247 (c) 2010 Intersect Healthcare, Inc. 50 50
  • 51. (c) 2010 Intersect Healthcare, Inc. 51 51
  • 52. Denise Wilson RRT, RN, MIS Director, Client Education and Performance Improvement 52
  • 53. • Understand how to incorporate Best Practice guidelines in appeals • Understand how to use regulatory and First Things First Planning CMS guidelines to bolster the appeal argument • What to say to an ALJ y (c) 2010 Intersect Healthcare, Inc. 53 53
  • 54. • Considerations for Deciding to Appeal – Cost – Time – Resources – Chance of Overturn First Things First Planning – Return on Investment • In addition to: – Root Cause Analysis – Education/Remediation Plan (c) 2010 Intersect Healthcare, Inc. 54 54
  • 55. • Close examination of decision letter – What are the instructions for appeal? – What forms do I need? – Where do I send my appeal? First Things First Planning – What was the issue? • Create Appeal Letter Templates pp p (c) 2010 Intersect Healthcare, Inc. 55 55
  • 56. Building the Foundation (c) 2010 Intersect Healthcare, Inc. 56 56
  • 57. CGI Federal RACB Issues CGI 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 • PIM Ch 6.5.3, Section A ‐ C ‐ DRG Validation Review • • First Things First Planning 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 / / (c) 2010 Intersect Healthcare, Inc. 57 57
  • 58. • Paint the Picture – Comorbidities and Complications (CC or MCC) – Medical Complexity • P Provide a Road Map id R dM First Things First Planning – Where is the Documentation? • Write to the ALJ – Best chance of overturn (c) 2010 Intersect Healthcare, Inc. 58 58
  • 59. • Use the Best Evidence – CMS Internet Only Manuals (IOM) – National Coverage Determinations; Local Coverage Determinations – ICD-9-CM Official Coding Guidelines – C di Coding Clinics Cli i First Things First Planning – Code of Federal Regulations (CFR) – Social Security Act – Evidence Based Guidelines, Position Statements, Expert Opinions from National Medical Associations (c) 2010 Intersect Healthcare, Inc. 59 59
  • 60. (c) 2010 Intersect Healthcare, Inc. 60 60
  • 61. (c) 2010 Intersect Healthcare, Inc. 61 61
  • 62. • 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  y Med 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  references] f ] (c) 2010 Intersect Healthcare, Inc. 62 62
  • 63. • Mark Forshag, MD, FCCP. “New Treatments for Sepsis.”  American College of Chest Physicians.  http://www.chestnet.org/education/online/pccu/vol17/lesso ns15_16/lesson15.php (accessed December 30, 2009). • Deborah Hale “Coding corner Is it sepsis?” ACP Hospitalist,  Deborah 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 (c) 2010 Intersect Healthcare, Inc. 63 63
  • 64. • 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 2009 Surviving Sepsis Campaign Facts, 2009.  http://www.survivingsepsis.org/About_the_Campaign/Page s/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. (c) 2010 Intersect Healthcare, Inc. 64 64
  • 65. (c) 2010 Intersect Healthcare, Inc. 65 65
  • 66. (c) 2010 Intersect Healthcare, Inc. 66 66
  • 67. (c) 2010 Intersect Healthcare, Inc. 67 67
  • 68. 42 CFR §§405 900 through 405.1064 §§405.900 405 1064 • ALJ Review Authority – Jurisdiction – Scope of Review • § 405 1062 Applicability of local coverage 405.1062 determinations and other policies not First Things First Planning 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 g , give substantial deference to these policies if they are applicable to a particular case. (c) 2010 Intersect Healthcare, Inc. 68 68
  • 69. 20 CFR 416.927: Evaluating Opinion 416 927: Evidence • Examining Relationship • Treatment Relationship – Length and Frequency g q y – Nature and Extent First Things First Planning • Supportability – Objective and Subjective Findings • Medical Signs and Laboratory Results (c) 2010 Intersect Healthcare, Inc. 69 69
  • 70. • Include an Attachments List • Include all Attachments – Electronic Copy • Use a Document Editor to Highlight the First Things First Planning Medical Record • Send all Communication via a Traceable Method (c) 2010 Intersect Healthcare, Inc. 70 70
  • 71. (c) 2010 Intersect Healthcare, Inc. 71 71
  • 72. Documentation, Coding Audit, and Appeal Workshops Sponsored by Intersect Healthcare Inc. Healthcare, Inc Next Session: Wednesday, June 23 1:00PM EST Respiratory Failure with Ventilator Support For more information or to view upcoming Webinar events, visit Intersecthealthcare.com 72

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