Sepsis Due to Localized Infection. If the type of infection or casual organism is not further specified, assign code A41.9, Sepsis, unspecified organism. In this case, the CAUTI falls into the category of “post procedural infection” and is assigned ICD-10 code T83.51, Infection and inflammatory reaction due to indwelling urinary catheter. If aspiration pneumonia is not considered infectious, then a code for sepsis cannot be assigned at all since the diagnosis of sepsis requires an underlying infectious cause. Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction. If the patient has organ dysfunction, e.g. However, as antibiotic resistance grows, infections are becoming more difficult to treat. There is also an Excludes1 for “severe sepsis” which is found in R65.2-. Bacteremia = The presence of viable bacteria in circulating blood. After the kidney function improved, the patient underwent surgery for care of the left heel. Q: We recently had a patient who was admitted with sepsis present on admission (POA) and a urinary tract infection (UTI). Sepsis also ranks in the top 10 of principal diagnoses leading to readmission. Commonly used terms In relation to septicemia, it is very common for people to use the term with the organism that causes the condition, or with the location the infection is or maybe with the condition itself. A code from subcategory R65.2 can never be assigned as a principal diagnosis. Is that correct? Other instances when sepsis would not be selected as the principal diagnosis, even if it was POA include the scenario where sepsis is the result of a condition which is classified as a “medical complication” (such as being due to an indwelling urinary catheter or central line. Sepsis without Positive Blood Cultures and … SIRS. Introduction. Retrospective Reviews: The last line of defense? Multiple Organ Dysfunction Syndrome (MODS) = Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention. A: In the first instance, when the patient was admitted with a UTI and sepsis, sepsis would be the principal diagnosis as long as it was present on admission. These readmissions were frequently due not just to infection but also to other acute conditions and seemed to result in substantially increased morbidity and mortality rates [ 7 , … When wouldn’t sepsis POA be principal? A code from subcategory R65.2, Severe sepsis, should NOT be assigned unless severe sepsis or an associated acute organ dysfunction is documented. The clinical manifestations would include two or more of the following conditions as a result of a documented infection. Specify if the patient has Sepsis or local infection (e.g. Sepsis and Severe Sepsis in a Localized Infection: If the reason for treatment is both sepsis and severe sepsis and a localized infection such as pneumonia or cellulitis, a code for the underlying systemic infection should be assigned first, and the code for the localized infection should be assigned as a secondary diagnosis. Specify if the patient has severe Sepsis. He has specialized in risk adjustment from the very beginnings of these models being utilized and has assisted large and small clients nationally. Case 1: A patient comes in with aspiration pneumonia and is seen choking on … Sepsis DRGs (sepsis is principal diagnosis) DRG Diagnosis RW GMLOS 870 Septicemia or Severe Sepsis w MV >96 Hours 6.09 12.5 871 Septicemia or Severe Sepsis w/o MV <96 Hours w MCC 1.82 4.9 872 Septicemia or Severe Sepsis w/o MV <96 Hours w/o MCC 1.05 3.7 DRG Diagnosis RW GMLOS 853 Infectious & Parasitic Diseases w OR Procedure w MCC 5.13 10.3 The trade-off for such a sensitive group of parameters that would alert physicians to the early manifestations of severe sepsis and septic shock was a group of criteria that lacked a great deal of specificity. Codes R65.20 and R65.21 as not acceptable as Principal diagnosis and must be sequenced after a code for the underlying systemic infection; A code from ICD-10-CM code subcategory R65.2- (severe sepsis) would not be reported unless the physician has documented severe sepsis or an acute organ dysfunction; Brian Boyce, BSHS, CPC, CPC-I, CRC, CTPRP is an AAPC-approved PMCC medical coding instructor, and ICD-10-CM trainer and the author of the AAPC CRC® curriculum. A: Likely, in the case you describe, the patient had sepsis that was due to a catheter-associated UTI (CAUTI). Severe sepsis may occur with or without sepsis-induced hypotension (e.g., with fever, encephalopathy and renal failure but a normal blood pressure). Do not document a procedure as the Principal Diagnosis. In this instance, I would likely code the complication code first with sepsis as a secondary diagnosis. If severe sepsis, or septic shock is also present, the appropriate additional code should also be assigned. As noted in the Tabular List, the code for septic shock CANNOT be assigned as a principal diagnosis. For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Post-procedural septic shock. When 'Urosepsis' is documented as the principal diagnosis on the discharge summary, what should be sequenced first, N39.0 Urinary tract infection, site not specified or A41.- If a patient is admitted because of bacteremia, it should be the principal diagnosis even though bacteremia is a symptom code, because it is the condition that occasioned the admission. In this scenario, however, the patient was admitted for shortness of breath, which was deemed to have been caused by an acute exacerbation of systolic congestive heart failure, and the focus of patient’s treatment was the heart failure exacerbation – which means that sepsis does not meet the definition of principal diagnosis and would not be sequenced first. QUESTION: I have two questions about coding sepsis and other conditions when both are present on admission (POA) and the physician treats both conditions equally. Final 2019 & Proposed 2021 CMS Physician Fee Schedule Changes, Maximum Diagnosis Codes Submission on Claim Forms, Understanding Important Facts Around the ACA and Potential Replacement or Revisions, Cultural Competency Series: Transgendered Patients, Understanding Sepsis, Severe Sepsis, & Septic Shock, Temperature above 101 F (38.3 C) or below 96.8 F (36 C), Respiratory rate higher than 20 breaths a minute or PaCO, A code for the underlying systemic infection, followed by. Felicity N.E. Any additional codes for any other acute organ dysfunction should also be assigned. A code from subcategory R65.2 can never be assigned as a principal diagnosis. Infection with associated acute organ dysfunction, Systemic Inflammatory Response Syndrome (SIRS) due to infectious process with acute organ dysfunction. I was under the impression that when sepsis is POA, it should always be coded as the principal diagnosis. The absence of fever in an infant less than 60 days old does not eliminate the possibility of sepsis. Note that “urosepsis” is a nonspecific term, and is not to be considered synonymous with sepsis. For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. ACDIS update: Regulatory Committee releases new insight on COVID-19 treatments add-on payments, Q&A: When sepsis isn’t the principal diagnosis. The principal elements of the most recent guidelines are summarized in this practice point. The coding of severe sepsis requires a minimum of 2 codes: If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. for COVID-19 in … acute kidney failure, list Sepsis, unspecified organism (A41.9) as the principal diagnosis, Severe sepsis (R65.2-), Acute kidney failure (N17.-), and Urinary tract infection, site not specified (N39.0) are listed as contributing diagnoses. If not you’re left with a conundrum: You have a patient who is sick with localized infection with bacteremia and we are treating it with the same fervor as sepsis, but it is not considered sepsis. When the chart was coded, UTI was listed as the principal diagnosis. The misinterpretation relates to the sequencing of codes. When severe sepsis develops during an admission (it was not present on admission) the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as secondary diagnoses. The sequencing of severe sepsis as a principal diagnosis also relies heavily on provider documentation. Patients receiving inotropic or vasopressor agents may no longer be hypotensive by the time they manifest hypoperfusion abnormalities or organ dysfunction, yet they would still be considered to have septic (SIRS) shock. The answer is in the Official Guidelines for Coding and Reporting, Section I.C.d.5.b: (b) Sepsis due to a post procedural infection. Hypoperfusion and perfusion abnormalities may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status. Using the National Inpatient Sample to examine temporal trends in diagnostic coding for a principal diagnosis of pneumonia, sepsis with a secondary diagnosis of pneumonia, or respiratory failure with a secondary diagnosis of pneumonia, Lindenauer et al. He went into physician practice management and medical coding after an honorable discharge. The definition of septic shock is severe sepsis with sepsis-induced hypotension [systolic blood pressure < 90 mm Hg (or a drop of > 40 mm Hg from baseline) or mean arterial pressure < 70 mm Hg] that persists after adequate fluid resuscitation. Severe Sepsis/SIRS = Sepsis (SIRS) associated with organ dysfunction, hypoperfusion, or hypotension. Gavins, in Vascular Responses to Pathogens, 2016. Antibiotics are critical tools for treating life-threatening infections, like those that can lead to sepsis. In most cases, especially when sepsis is present on admission, sepsis will be the principal diagnosis.17 COVID-19 is classified as a MCC when sequenced as a secondary diagnosis leading to MS-DRG 870 (Septicemia or severe sepsis with mechanical ventilation > 96 hours, when applicable) or MS-DRG 871 (Septicemia or severe sepsis without MV > 96 hours with MCC). When COVID-19 meets the definition of principal diagnosis, code U07.1, COVID-19, should be sequenced first, followed by the appropriate codes for associated manifestations, except in the case of obstetrics patients as indicated in Section I.C.15.s. Sepsis Due to a Post-procedural Infection: The provider’s documentation must link the cause of the infection being due to the procedure. Note that there is an Excludes1 here for sepsis, which instructs coders to code to the infection. Without the diagnosis of sepsis falling into one of those chapters, coders should follow the ICD-10-CM Official Guidelines for Coding and Reporting of sepsis, severe sepsis and septic shock. Given its importance in terms of morbidity and mortality, a number of initiatives by several professional societies in recent years have led to the development of guidelines for the recognition and timely management of sepsis. Any additional codes for any other acute organ dysfunctions should also be assigned. Under ICD-10 rules and conventions, the CAUTI is required to be sequenced as the principal diagnosis over the ICD 10 code for sepsis, A41. Sepsis is a systemic inflammatory response to suspected or proven infection. The Ninth edition changes instruct coders to assign two codes for documentation of 'Urosepsis', following the lead term 'Urosepsis' - See Sepsis and Infection, urinary. Sepsis due to E coli. A code from subcategory 2, Severe sepsis. He is the CEO of ionHealthcare® LLC, a company that specializes in healthcare consulting, risk adjustment coding, management & support services. Common signs and symptoms include fever, increased heart rate, increased breathing rate, and confusion. Septic shock is a life-threatening complication of sepsis that often results in death. For all cases of septic shock, the code for the underlying systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock. Sepsis is a systemic inflammatory response to the presence of suspected or proven infection. This initial stage is followed by suppression of the immune system. To accomplish this goal, the conference participants aimed to use readily available clinical signs, symptoms and basic laboratory studies that would then support a rapid diagnosis. There are in fact some instances where sepsis may be present, but not selected as the principle diagnosis. For such cases, the post-procedural infection code, such as T80.2, Infections following infusion, transfusion, and therapeutic injection; T81.4, Infection following a procedure; T88.0, Infection following immunization; or O86.0, Infection of obstetrical surgical wound, should be coded first, followed by the code for the specific infection. I know the guidelines for coding sepsis, but I have to question them in two scenarios for which I was told to use sepsis as my principal diagnosis. To be diagnosed with septic shock, the patient will have signs and symptoms of severe sepsis, plus extremely low blood pressure that does not respond to simple fluid replacement. Multiple studies document up to a 26% risk of readmission. Sepsis is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. (Septic shock indicates severe sepsis is also present.) Prevention, early diagnosis and treatment at the earliest possible occasion help to prevent the complications and problems that may arise due to sepsis. Document diagnosis where possible rather than impression. All rights reserved. Post was not sent - check your email addresses! x. Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for HCPro in Middleton, Massachusetts, answered this question. Neither the sepsis nor the heel ulcer should be sequenced as principal diagnosis at facility B because they did not necessitate the transfer for care. Doctors and nurses should treat sepsis with antibiotics as soon as possible. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1. Posted By Brian Boyce on October 24, 2016. In North America, at the time of going to press, over one million cases of sepsis occur annually, with 40% leading to severe sepsis (3% of those with severe sepsis experience septic shock) and 300,000 deaths. The principal diagnosis is the reason (intent) for transfer – the acute kidney failure. He has special interest in ethics, patient safety, disease management, and management and leadership of people. SIRS is the body’s clinical cascading response to infection or trauma that triggers an acute … should be sequenced first, followed by the code 995.92, SIRS due to infectious process with organ dysfunction. SIRS (Systemic Inflammatory Response Syndrome) = The systemic inflammatory response to a wide variety of severe clinical insults, manifested by two or more of the following conditions: Sepsis = The systemic inflammatory response to infection and is defined as the presence of SIRS (Systemic Inflammatory Response Syndrome) in addition to a documented or presumed infection. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis. Sepsis often results from infections to the lungs, stomach, kidneys, or bladder. Other instances when sepsis would not be selected as the principal diagnosis, even if it was POA include the scenario where sepsis is the result of a condition which is classified as a “medical complication” (such as being due to an indwelling urinary catheter or central line. 3) Sequencing of severe sepsis If severe sepsis is present on admission, and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List. The term “severe sepsis” includes the following alternative wording: If severe sepsis is present on admission, and meets the definition of a principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2, as required by the sequencing rules in the Tabular List. Tachycardia, tachypnea, and hyperthermia are classic features [ 7][ 10]. In some cases, bloodstream infection cannot be detected, and doctors use other information such as body temperature and mental status to diagnose sepsis. Sometimes, sepsis can occur in … UTI) Specify organism for the Sepsis e.g. SIRS, Systemic Inflammatory Response Syndrome is found in R65.1-. One such example is when the sepsis was not POA. If severe sepsis is present on admission, and meets the definition of a principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2, following the sequencing rules in the Tabular List. Brian is a veteran of Desert Storm, where he served on active duty with the US Air Force with a job specialty of Aeromedical Evacuation. If severe sepsis is clearly present on admission and meets the definition of principal diagnosis, the systemic infection code (038.xx, 112.5, etc.) Sepsis is usually considered severe when the patient exhibits at least one of the following signs and symptoms (which may indicate an organ may be failing): Refractory (Septic) Shock/SIRS Shock = A subset of severe sepsis (SIRS) and defined as sepsis (SIRS) induced hypotension despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status. Some would always assign the localised infection as principal diagnosis followed by the sepsis code, which adds the severity of the infection; whilst others would apply ACS 0001 Principal diagnosis to determine the sequencing of localised when there is a generalised infection also present. Also note that the concept of SIRS is that it is of “noninfectious origin.”. Copyright © 2021 HCPro, a Simplify Compliance brand. A code from subcategory R65.2 can never be assigned as a principal diagnosis. Sepsis is a major cause of death and disability worldwide. For such cases, the post procedural infection code, such as T80.2, Infections following infusion, transfusion, and therapeutic injection, T81.4, Infection following a procedure, T88.0, Infection following immunization, or O86.0, Infection of obstetric surgical wound, should be coded first, followed by the code for the specific infection. Infection = A host response to the presence of microorganisms or tissue invasion by microorganisms. The aim of the study was to assess the diagnostic usefulness of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in sepsis, severe sepsis and septic shock against interleukin-6 (IL-6), C-reactive protein (CRP) and procalcitonin (PCT). Introduction. Sepsis and Severe Sepsis • “For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If aspiration pneumonia is considered infectious, sepsis must be assigned as the principal diagnosis. Specify if the patient has SIRS. Additional codes for any associated acute organ dysfunction are also required. Contact him at AFrady@hcpro.com. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism.” If sepsis is documented with organ dysfunction or multiple organ dysfunction (MOD), then follow the rules for coding severe sepsis. Coding of Septic Shock When severe sepsis develops during an admission (it was not present on admission) the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as secondary diagnoses. When sepsis is present on admission and due to a localized infection (not a device or post procedural), the sepsis code is sequenced first followed by the code for the localized … Sensitivities and specificities of clinical signs and biochemical tests in sepsis diagnosis are not satisfactory. Sorry, your blog cannot share posts by email. For additional inquiries contact ionHealthcare® at info@ionHealthcare.com. If the sepsis results from an indwelling catheter or a complication of a device, the complication code would be sequenced first.