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The Sepsis Code: discover the secret to coding it right the first time
The presentation by Laura Legg focuses on the complexities of coding sepsis in hospitals, highlighting the significant costs associated with sepsis care, estimated at $20.3 billion annually in the U.S. It outlines specific challenges in sepsis documentation and coding, emphasizing the need for clear clinical indicators, physician queries, and effective documentation practices. The presentation advocates for multidisciplinary approaches to improve coding accuracy and protect hospital revenue related to Diagnosis Related Groups (DRGs) 870-872.
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The Sepsis Code: discover the secret to coding it right the first time
- 1. Laura Legg RHIT, CCS,CDIP, AHIMA approved ICD- 10 CM/PCS Trainer HRG Executive Director of Revenue Integrity and Compliance Presented by:
- 2. Disclaimer This PowerPoint presentationis an education tool to provide basic information for coding. The information is the sole view of the author and was put together based on experience, research and expertise in the coding profession. It is not intended to be an exhaustive review and should not be considered a substitution for Coding Guidelines. The presenter does not accept any responsibility or liability with regard to errors, omissions misinterpretations or misuse by the audience.
- 3. Objectives answer the questionwhy is sepsis so challenging for hospitals examine sepsis coding challenges identify areas to focus for clinical documentation opportunities review a multidisciplinary approach to protect revenue for DRGs 870-872 learn how to take advantage of pre-audits for reputation and reimbursement hrgpros.com
- 4. High Dollar Diagnoses Source: AHRQHealthcare Cost and Utilization Report, August 2014 Pneumonia $10.5 Billion Congestive Heart Failure $10.5 Billion Acute Myocardial Infarction $11.5 Billion Sepsis $20.3 Billion Respiratory Failure $8.7 Billion
- 5. $epsis Costs most expensive reason for hospital- ization U.S.spent $20.3 billion dollars on hospital care for patients with sepsis in 2013 (the most recent published data) $55,616,438 on sepsis care per day in U.S. hospitals average hospital stay for sepsis costs approximately double a stay for another diagnosis annual rate of growth of sepsis costs in hospitals is three-times the rate for hospital costs overall sepsis patients stay in the hospital 75% longer than other patients – impacting the ability for hospitals to move patients out of the emergency department and into hospital beds survivors of sepsis are more likely to be discharged to a place other than home after the hospital and suffer readmissions at a high rate, costing approximately $2B per year
- 6. Face of Sepsis™Presented by Sepsis Alliance https://youtu.be/12Qbnn6XfH0
- 7. Sepsis Coding Challenges coders knowledge ofA&P complexity of record review & LOS unclear definitions availability of resources physician documentation challenges extensive coding guidelines OIG hit list and payer target
- 8.
- 9. Sepsis Defined Septic Shock circulatory failureassociated with severe sepsis Severe Sepsis sepsis with associated acute organ dysfunction Sepsis systemic response to infection
- 10. ICD-9-CM vs. ICD-10CM ICD-9-CM ICD-10-CM
- 12. Decoding Sepsis Signs &Symptoms • fever, shaking chills, confusion, agitation • cyanosis or pallor • complications include: septic shock, respiratory failure, acute kidney failure, hepatic failure • tachycardia • hypotension Treatment Activity • antibiotic therapy (IV) • fluids and pressors to maintain blood pressure • activated protein C Xigris • oxygen Medications • antibiotics: gentamicin, penicillin, ampiciliin, cephalosporin, nafcillin or oxacillin, cefazolin, vancomycin • vasopressors Lab Diagnostic Test • blood culture for causative organism • CBC • PCT Assay • wound culture • urinalysis
- 13. Coding Sepsis diagnosis ofsepsis should be based on physician documentation coder should not assume a patient has sepsis based solely on blood culture results patient may show clinical signs of sepsis despite negative blood cultures clinical indicators positive blood cultures exception: negative or of inconclusive blood cultures do not preclude a diagnosis septicemia or sepsis in patients with clinical evidence…however the provider should be queried CC 3rd Q1988 only 28% of patients with sepsis have positive BCs
- 14. Coding Sepsis Terms septicemiaand sepsis - although the terms are often used interchangeably by providers, they are not considered synonymous terms in coding urosepsis - term often used by providers to describe both sepsis and a urinary tract infection Coding Sepsis Tips determine if the term urosepsis is being used to describe sepsis or urinary tract infection if conflicting documentation is found within the medical record stating both a diagnosis of urosepsis and septicemia, the physician should be queried to determine which diagnosis is intended
- 15. Severity Of Illness LowerSOI Higher SOI severe hypoxia (S&S) early or mild acute respiratory failure urosepsis UTI with sepsis severe COPD on continuous O2 chronic respiratory failure take SOI to the next level
- 16. Sepsis Documentation -Adult Sepsis: manifested by two or more of the following not easily explained by another co-existing condition: Temperature: > 38.3 degrees C or hypothermia <36.0 degrees C WBC >12,000 or < 4,000 or Bands >10% Lactate >2.0 mmol/L Tachycardia >90 Tachypnea >20 Procalcitonin elevated C-reactive protein elevated altered mental status Mottling of the skin or prolonged capillary refill Non-diabetic hyperglycemia BS >120mg/dl Other evidence of acute organ failure (severe sepsis) The first five criteria are commonly given the greatest weight but any and all of the criteria may be used by physicians to establish a diagnosis of sepsis based on their clinical judgement. The more indicators the patient has the more certain the diagnosis will be. The clinical indicators being present and their significance must be documented by the physician clearly and consistently throughout the patient’s record.
- 17. Sepsis-Message To Providers documentationthread of the sepsis diagnosis should be reflected throughout the patient’s stay, if treated and resolved then document sepsis resolved include sepsis diagnosis in the discharge summary indicate whether or not sepsis was POA and also its severity (Severe Sepsis Septic Shock)
- 18. Sequencing Tips sepsis isnot always the principal diagnosis only code it as principal DX if present on admission and meets definition of principal DX sepsis with localized infection: sepsis must be the principal DX • in only a few cases is the localized infection the principal DX • ex: candida septicemia and line infection (CC 1989 2nd Q and CC 2004 2nd Q) coder cannot assume the linkage between sepsis and an underlying localized infection - provider must make the link • ex: pneumonia, osteomyelitis or a urinary tract infection. (CC 4th Q 2011)
- 19. don’t assume code assignmentis based on the provider’s documentation of the relationship between the infection and the procedure the complication code other postoperative infection should be PDX followed by the appropriate sepsis codes sepsis due to a post- procedural infection Special Cases- Sepsis
- 20. Organ Failure renal, heartand respiratory failure often accompanied by encephalopathy if a patient has sepsis and acute organ dysfunction, but the chart indicates the dysfunction is related to a diagnosis other than sepsis an acute organ dysfunction must be associated with sepsis to assign the code for severe sepsis - query if you can’t tell respiratory failure due to COPD (not sepsis)
- 21. Querying Musts know yourindicators for sepsis use key documents as indicators to query • example: sepsis orders querying clarifies inconclusive or contradictory documentation it also helps providers improve their documentation if documentation is not clear whether sepsis/severe sepsis was present on admission – QUERY (CC 2007 4th Q) • sepsis may be present on admission but the dx may not be confirmed until after admission
- 22. when the health recorddocumentation: is conflicting, imprecise, incomplete, illegible, ambiguous or inconsistent describes or is associated with clinical indicators without a definitive relationship to an underlying dx includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure provides a diagnosis without underlying clinical validation is unclear for present on admission indicator assignment To Query, Or Not To Query…that is the query when in doubt, Centers for Medicare and Medicaid Services (CMS) has instructed coders to ‘refer to the Coding Clinic guidelines and query the physician when clinical validation is required’
- 23. Facility Best PracticeFor Querying accredited coders/CDI staff linkage to physician advisors & quality staff 3d’s define, document, defend (using approved definitions) support quality measures and generate ACCURATE coding to support risk- adjusted outcomes data
- 24. 29 Define – Document- Defend
- 25. Sepsis Starting Line screening toolto look for clinical indicators of sepsis look for blood cultures make sure there isn’t a procedure make sure there isn’t any other PDX find/verify CC/MCCs verify the sepsis with the discharge summary or query
- 26. Case Study #1 Thepatient, with arteriosclerotic coronary heart disease and type 2 diabetes mellitus, came to the hospital with symptoms that were felt to represent sepsis. She was placed on antibiotics and the symptoms improved. ST and T-wave changes were evident on the EKG. The patient’s glucose showed marked elevation, thought to be secondary to sepsis. The blood sugars were brought under control with an adjustment of her insulin therapy and an appropriate diet.
- 27.
- 28. Case Study #1Rationale admission was necessitated by signs and symptoms felt to represent sepsis, payer disputed the “felt to be sepsis”. . .where is the localized infection? missing clinical indicators CDI identify the lack of clinical indicators early and query regarding the localized infection coding can then code the Sepsis code and the localized infection if not, provider documents “sepsis, ruled out” for the diabetes code, see the main term diabetes in the alphabetic index and the sub term inadequately controlled, with the cross reference that states “code to diabetes, by type, with hyperglycemia no code is assigned for the ST and T wave changes on the EKG because they represent abnormal findings that were not treated or further evaluated code Z79.4 is assigned because the patient is on insulin therapy would you need a query for this case??
- 29. Case Study #2 The patient is an 85y.o. female who presents to the ER with increasing shortness of breath, hypoxia, productive cough, and progressive weakness. Clinical indicators: temp 102, HR 110, RR 28, Lactic acid 3.2, WBC 24,000. She acutely deteriorated in the ER and was emergently sent to the intensive care for intubation. Mechanical ventilation lasted for four days and in addition broad-spectrum antibiotics were given. Diagnosis: severe sepsis with septic shock due to hemophilus influenza pneumonia, with acute respiratory failure.
- 30.
- 31. Case Study #2Rationale for cases of severe sepsis, the underlying infection is sequenced first, followed by a code from subcategory R65.2 severe sepsis when the reason for admission is both sepsis and the localized infection (e.g. pneumonia) the code for the localized infection should be assigned as a secondary diagnosis would you need a query for this case??
- 32. The Documenting ConsequencesOf Sepsis not insufficiencyAcute Kidney Failure not hypoxia Acute Respiratory Failure not weakness Critical Illness Myopathy not coagulopathyDIC not AMSEncephalopathy not elevated liver enzymesAcute Hepatic Failure not hypotensionSeptic Shock state ALL manifestations of sepsis in the discharge diagnosis
- 33. Importance Of ReliableDocumentation all through the record H&P, progress notes, & discharge summary documents all significant conditions must be consistent with documentation in the body of the record - if not, query the physician should clarify if conditions were POA and if they have resolved, are still to be ruled out or were in fact ruled out Documentation Examples: • admission note: “sepsis with septic shock secondary to pneumonia” • progress note: “sepsis, and shock improving” • discharge summary: “sepsis, septic shock and pneumonia, resolved”
- 34. Self-Auditing ensure all expiredcases are reviewed systematically by clinician and coder prior to final coding review cases with code assignment for severe sepsis - severe sepsis implies an organ failure review cases with major infections that ARE NOT coded to sepsis examples: patients with pneumonia, SBP, cholangitis, focus on those with high charges and/or extended LOS (GMLOS per MS- DRG Methodology)
- 35. Role Of TheCoder clinical indicators without physician documentation documented diagnoses without clinical evidence to “validate” the diagnosis 2 common challenges coders play a key role in ensuring existing documentation supports listed diagnoses and procedures
- 36. Identify Documentation IssuesPrior To Final Code Assignment understand how clinical validation relates to code assignment have an effective CDI program work as a team with coding - CDI and physicians focus on documentation concurrently - retrospective queries will not solve this problem Coding Goal
- 37. Practical Application: if thephysician documents sepsis and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician's diagnosis, that is a clinical issue, but it is not a coding error facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system hrgpros.com
- 39. Bring It AllTogether: Performance Improvement Plan identify missed, vague or under-documented clinical conditions for sepsis before discharge maybe different for each facility no physician groups document the same takes the whole team begin by focusing on sepsis admissions Example: Sepsis
- 40. Medical Staff LeaderRole • process lead by medical director or physician leader • medical staff will have to adopt definition by consensus of physician leaders • hospital-wide standard set by Med Exec approval • facility policy to reference documentation create definition for clinical conditions of sepsis, severe sepsis, and septic shock
- 41.
- 42. SEPSIS: Pre-Bill Reviews 1.uncover missed documentation, coding, and query opportunities 2. promote coding accuracy to drive revenue integrity and mitigate financial risk 3. ensure accurate coding and reporting of quality measure cohorts and risk adjustment 4. reflect accurate clinical complexity of patients, especially for at-risk populations 5. pinpoint educational opportunities for coders, clinical documentation improvement (CDI) specialists, and physicians 6. strengthen physician advisor programs by generating actionable data 7. reduce denials and associated costs for claims rework, audits, and appeals
- 43. Conclusion sepsis is challenging due tothe differing definitions that cross clinical care and coding develop definitions for septic shock, severe sepsis and sepsis coders become proficient at recognizing and coding severe sepsis and assist in improving documentation for a diagnosis of sepsis the patient must be described as “septic” or “toxic” appearing through the provider documentation
- 44. YourPartner@hrgpros.com •questions •comments •CEU request (deliverywithin 7 days) hrgpros.com
- 45.
- 46. hrgpros.com Laura Legg, RHIT, CCS,CDIP, AHIMA Approved ICD-10 CM/PCS Trainer HRG Executive Director of Revenue Integrity & Compliance Visit us online for more information on HRG’s CDI program and Laura’s upcoming speaking engagements! hrgpros.com/CDI 800.695.8171 YourPartner@hrgpros.com @hrgpros