Embed Size (px)
Citation preview
SepsisNew Guidelines, New Codes
Barry Libman, RHIA, CCS, CCS-P
President
Barry Libman Inc.
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
790.7 Bacteremia
Presence of bacteria in the blood
Use additional code to identify organism (041)
Excludes Bacteremia of newborn (771.83)
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)
Septicemia and Sepsis
Septicemia and Sepsis are no longer synonymous terms
AHA Coding Clinic for ICD-9-CM, Fourth Quarter, 2003
Coding “Sepsis”
Sepsis requires two codes
Underlying condition 038.x
and
995.91 or 995.92
Per Instructional notes in Tabular Index.
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.
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
Source: Bone et al. Source: Bone et al. ChestChest 1992;101:1644 1992;101:1644
SIRS Continuum
SIRSINFECTION
PANCREATITIS
BURNS
TRAUMA
OTHER
SEPSIS
SEVERESEPSIS
SEPTICSHOCK
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
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
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)
995.9x SIRS sequencing
Sequence
1. underlying condition
2. SIRS 995.9x
3. any organ dysfunction
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)
Mortality
Septic Shock
53-63%
20-53%Severe Sepsis300,000
7-17%Sepsis
400,000
Incidence
Source: Balk, R.A. Crit Care Clin 2000;337:52
Mortality Increases in Septic Shock Patients
Approximately 200,000 patients including 70,000 Medicare patients have septic shock annually
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
V09.x Resistance to Microorganisms
Drug Resistant Organisms
Resistance to Methicillin V09.0
Other common drug resistance?
Example: Bacteremia
Bacteremia (cause unknown) Blood cultures growing E coli per MD
documentation
790.7 Bacteremia
041.4 E coli organism
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
Example: Streptococcal Septicemia/Sepsis Streptococcal Septicemia
(documented as septicemia)
038.0
Streptococcal Sepsis
(SIRS and documented infection)
038.0
995.91
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)
Example: SIRS
SIRS due to acute pancreatitis
577.0 Acute Pancreatitis
995.93 SIRS (no-infection, without organ dysfunction)
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
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
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)
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
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)
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.
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
