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Sepsis: Understanding the Confusion VHIMA Annual Convention

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Title: Sepsis: Understanding the Confusion VHIMA Annual Convention


1
Sepsis Understanding the ConfusionVHIMA Annual
Convention
  • April 24, 2008
  • Donna Stickley, MD, FACEP

2
Objectives
  • Understand the terminology
  • Epidemiology
  • Diagnosis and Treatment
  • Coding Considerations

3
Definitions Key to Understanding

4
Escape Key

5
Consensus Conference 1991
  • Consistent definition for sepsis
  • Tools for improving detection of sepsis
  • Standardization of nomenclature to advance sepsis
    research
  • Critical Care Medicine 199220864-874

6
Systemic Inflammatory Response Syndrome
  • Clinical syndrome defined by the presence of two
    or more of the following
  • Fever gt 100.4 or hypothermia lt 96.8
  • Leukocytosis gt 12,000 or
    leukopenia lt4,000 or gt10bands
  • Tachycardia gt90 beats per minute
  • Tachypnea RRgt20 breaths per minute

7
SIRS Criteria
8
Causes of SIRS
  • Sepsis
  • Severe Sepsis
  • Septic Shock
  • Pancreatitis
  • Burns
  • Trauma
  • Other

9
SIRS Continuum
PANCREATITIS
INFECTION
SIRS
BURNS
SEPSIS
SEVRE SEPSIS
SEPTIC SHOCK
TRAUMA
OTHER
Bone at al. Chest 1992 101 1644
10
Sepsis
  • Definition SIRS due to a suspected infection

11
Bacteremia
  • Definition Laboratory finding of viable bacteria
    in the blood
  • Positive blood culture
  • Blood Stream Infection (BSI)
  • Contaminant

12
Septicemia
  • Out dated ambiguous term
  • In past used to imply sepsis or bacteremia
  • Generally used to indicate sepsis with BSI

13
Severe Sepsis
  • Definition Sepsis with acute organ dysfunction
    or multiple organ dysfunction

14
Organ dysfunction
  • Acute renal failure
  • Acute respiratory failure
  • Disseminated intravascular coagulopathy
  • Encephalopathy
  • Hepatic failure
  • Septic shock

15
Septic Shock
  • Definition severe sepsis with hypotension
    (systolic blood pressure lt 90 mmHg) unresponsive
    to fluids

16
Sepsis
  • Complex medical syndrome
  • Difficult to define, diagnosis and treat
  • Caused by the bodies response to infection

17
Physicians confused too!
  • Majority agree leading cause of mortality in ICU
  • Only 22 use the concensus criteria when defining
    sepsis
  • Only 17 agree on the definition of sepsis

18
Consensus Conference 2002
  • International panel of experts
  • Reviewed state of knowledge of sepsis
  • No change in definitions

19
Epidemiology
  • Over 18 million cases of severe sepsis worldwide
    each year
  • 750,000 cases of sepsis a year in the United
    States
  • Growing number of cases 1.5 annually
  • Cost more than 17.4 billion

20
Mortality
  • 215,000 death in U.S. each year
  • Kills 1,400 people worldwide every day
  • Severe sepsis 25-30 mortality
  • Septic Shock 40-70 mortality

21
Personal Impact
  • Patient often long hospitalizations
  • Family care after hospital
  • Personal cost disability, suffering,
    psychological affect
  • Survivors decrease quality of life

22
Clinical Evaluation
  • History
  • Possible source of infection
  • Risk factors
  • Fevers or shaking chills
  • Altered mental status

23
Physical Exam
  • May suggest source of infection
  • Central lines
  • Abdominal Exam
  • Skin Exam
  • May be unrevealing

24
Work up
  • Lab
  • Blood culture
  • CBC
  • Urine
  • others
  • Chest X- ray

25
Surviving Sepsis Campaign
  • Developed to improve the management, diagnosis
    and treatment of sepsis
  • Goal to decrease mortality
  • Developed guidelines for management
  • survivingsepsis.org

26
Treatment
  • Antibiotics
  • IV antibiotics within one hour of diagnosis
  • Broad spectrum
  • Reassess daily
  • Duration 7-10 days

27
Treatment
  • Fluid Therapy
  • Vasopressors increase BP
  • Steroids
  • Recombinant human activated protein C (rhAPC)

28
Coding Considerations
  • Diagnosis of Sepsis challenging
  • Ambiguous provider documentation
  • Coding guidelines

29
Urosepsis
  • The Problem
  • Definition Sepsis resulting from the
    decomposition of extravasated urine (from
    Stedmans Medical Dictionary)
  • Encourage physicians to remove urosepsis from
    their vocabulary

30
Coding SIRS
  • Requires a minimum of two codes
  • Code for the underlying cause or infection
  • Code from subcategory 995.9x, systemic
    inflammatory response syndrome

31
Sepsis
  • Coding definition SIRS due to infection
  • Requires a minimum of two codes
  • Code for systemic infection (038.xx)
  • Code for 995.91 SIRS due to infection without
    organ dysfunction

32
Sequencing Sepsis
  • Dependent on physician documentation
  • If present on admission and meets definition of
    principal diagnosis
  • Systemic infection first
  • SIRS due to infectious process without organ
    dysfunction next
  • Develops after admission sequence both as
    secondary codes

33
Severe Sepsis
  • Definition SIRS due to infection with organ
    dysfunction
  • Requires a minimum of three codes
  • Code for Systemic infection (e.g. 038.xx)
  • Code for severe sepsis (995.92)
  • Code for associated organ failure

34
Sequencing for Severe Sepsis
  • Depends on provider documentation
  • If POA and meets principal diagnosis definition
  • Systemic infection first
  • Severe sepsis 995.92
  • If develops during stay code both as secondary
    diagnosis

35
Septic Shock
  • Circulatory failure associated with severe
    sepsis
  • Represents a type of organ dysfunction
  • Septic shock meets the definition of severe
    sepsis
  • Follow coding and sequencing guidelines for
    severe sepsis
  • Code also 785.52 septic shock

36
Septic Shock
  • Code
  • Systemic infection 038.xx
  • Severe sepsis 995.92
  • Organ dysfunction
  • Septic Shock 785.52

37
Sepsis with Localized Infection
  • If reason for admission is sepsis and a localized
    infection, code systemic infection first
  • If reason for admission is localized infection
    and sepsis develops, code localized infection
    first

38
Example 1
  • Patient admitted with pneumonia, respiratory
    failure and sepsis
  • How would you sequence them?

39
Example 2
  • Patient admitted with pneumonia and respiratory
    failure. After admitted develops sepsis.
  • How would you code this?

40
Example 3
  • Patient admitted with fever and weakness has
    sepsis from indwelling central line
  • How would you code this?

41
Example 4
  • Patient presents with a fever and a painful
    swollen joint. Diagnosed with septic arthritis
    and sepsis
  • How would you code this?

42
Summary
  • Know the definitions
  • Know the Coding Guidelines
  • Know when to query

43
QUESTIONS?
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