Sepsis New Guidelines, New Codes

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SepsisNew Guidelines, New Codes

• Barry Libman, RHIA, CCS, CCS-P
• President
• Barry Libman Inc.

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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

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790.7 Bacteremia

• Presence of bacteria in the blood
• Use additional code to identify organism (041)
• Excludes
• Bacteremia of newborn (771.83)

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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)

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Septicemia and Sepsis

• Septicemia and Sepsis are no longer synonymous
  terms
• AHA Coding Clinic for ICD-9-CM, Fourth Quarter,
  2003

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Coding Sepsis

• Sepsis requires two codes
• Underlying condition 038.x
• and
• 995.91 or 995.92
• Per Instructional notes in Tabular Index.

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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.

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995.9x SIRS

• Two or more of the following
• Temperature gt38 C or lt36 C
• Heart Rate gt 90 beats per minute
• Respiratory Rate gt 20 breaths per minute or PaCO2
  lt 32 mm Hg
• White Blood Cell Count gt 12,000/cu mm, lt4,000/cu
  mm or gt10 immature (band) forms

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SIRS Continuum
Source Bone et al. Chest 19921011644
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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

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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

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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)

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995.9x SIRS sequencing

• Sequence
• 1. underlying condition
• 2. SIRS 995.9x
• 3. any organ dysfunction

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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)

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Mortality Increases in Septic Shock Patients
Mortality
Incidence
Approximately 200,000 patients including 70,000
Medicare patients have septic shock annually
Source Balk, R.A. Crit Care Clin 200033752
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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

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V09.x Resistance to Microorganisms

• Drug Resistant Organisms
• Resistance to Methicillin  V09.0
• Other common drug resistance?

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Example Bacteremia

• Bacteremia (cause unknown)
• Blood cultures growing E coli per MD
  documentation
• 790.7 Bacteremia
• 041.4 E coli organism

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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

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Example Streptococcal Septicemia/Sepsis

• Streptococcal Septicemia
• (documented as septicemia)
• 038.0
• Streptococcal Sepsis
• (SIRS and documented infection)
• 038.0
• 995.91

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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)

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Example SIRS

• SIRS due to acute pancreatitis
• 577.0 Acute Pancreatitis
• 995.93 SIRS (no-infection, without organ
  dysfunction)

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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

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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

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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)

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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

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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)

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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.

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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

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Questions?

• Barry Libman, RHIA, CCS, CCS-P
• Barry Libman Inc.
• 978-369-7180
• blibman_at_barrylibmaninc.com