Sepsis Syndrome
I am looking at a chart that says: “Sepsis syndrome w/DIC”. I found the following coding clinic and it makes it sound as though I don’t need to clarify Sepsis Syndrome. Am I interpreting that correctly? Thanks for your input!!
AHA Coding Clinic® for ICD-9-CM, 2Q 2000, Volume 17, Number 2, Pages 3-7
Sepsis syndrome comprises septicemia with evidence of inadequate organ perfusion with at least some degree of one or more of the following: hypoxemia (PaO2< 75 mmHg); elevated lactate (>5 meq/L); oliguria (< 30mL/hr urine); altered mentation (Glasgow coma score); disseminated intra-vascular coagulopathy (DIC); decreased platelets; increased INR; and/or increased fibrin split prod-ucts (FSP).
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org
AHA Coding Clinic® for ICD-9-CM, 2Q 2000, Volume 17, Number 2, Pages 3-7
Sepsis syndrome comprises septicemia with evidence of inadequate organ perfusion with at least some degree of one or more of the following: hypoxemia (PaO2< 75 mmHg); elevated lactate (>5 meq/L); oliguria (< 30mL/hr urine); altered mentation (Glasgow coma score); disseminated intra-vascular coagulopathy (DIC); decreased platelets; increased INR; and/or increased fibrin split prod-ucts (FSP).
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org
Comments
Unfortunately coding clinic clarified this with latest coding clinic. You will need to query.
Sepsis syndrome clarification
Coding Clinic, Second Quarter 2012 Pages: 21-22 Effective with discharges: July 17, 2012
Question:
The provided listed "sepsis syndrome" in the final diagnostic statement. How should sepsis syndrome be coded? The only advice we have found on sepsis syndrome was a Coding Clinic reference from Second Quarter 2000 regarding septicemia, septic shock and sepsis syndrome. Is that advice still valid?
Answer:
No, the coding advice on sepsis has changed since that Coding Clinic reference was published. The term "sepsis syndrome" is poorly defined. Query the physician to determine the specific condition(s) the patient has.
Dorie Douthit, RHIT,CCS
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org
Ugh – I 100% understand we are compelled to follow the ‘law’ of Coding Clinic, but this one seems a bit Draconian IMO. When we have a pt with DIC and other supporting clinical evidence supporting Sepsis, this seems not logical. However – ‘it is what it is’. Just my frustration on this topic given I am using Quantim and I don’t have access yet to 2nd Qtr of 2012, so I had not seen this issue of Coding Clinic.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org
3M seems to make this vital reference available on a more timely basis - I am not sure why this is so.
Paul
Has anyone else implemented the advice about sepsis syndrome in the most recent coding clinic update? Our facility has been coding sepsis syndrome as sepsis forever and this looks like one more battle to fight in the ongoing sepsis war. I'd love to hear any feedback from other CDI Professionals!
Kevin O'Neil, RHIT
Herrin Hospital
Herrin, IL
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Jamie Dugan RN
Clinical Documentation Improvement Specialist
Baptist Health System
office:904-202-4345
cellular: 904-237-7253
Business Email-jamie.dugan@bmcjax.com
cdis.icd10@bmcjax.com
Linda Haynes, RHIT, CCDS | Clinical Documentation Manager | Legacy Health | Portland, Oregon |
P: 503-415-5609 | lhaynes@lhs.org
Tara
I'd love to use something similar to our "urosepsis" query which basically states that urosepsis is documented and asks them to clarify whether when they use this term they are referring to sepsis 2/2 UTI or UTI (other, unable to determine). However, in this case, there isn't really an alternative, just the suggestion to query when we see it.
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Thanks,
Tara
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Jamie Dugan RN
Clinical Documentation Improvement Specialist
Baptist Health System
office:904-202-4345
cellular: 904-237-7253
Business Email-jamie.dugan@bmcjax.com
cdis.icd10@bmcjax.com
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Hope they help!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Claudine Hutchinson RN
Clinical Documentation Improvement Specialist
Children's Hospital at Saint Francis
Email: chutchinson@saintfrancis.com
Office: (918) 502-6603
Pager: 98-1001
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Claudine Hutchinson RN
Clinical Documentation Improvement Specialist
Children's Hospital at Saint Francis
Email: chutchinson@saintfrancis.com
Office: (918) 502-6603
Pager: 98-1001
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Kevin
Karen McKaig, BSN, RN, CCM, CPUR, CCDS
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Francisca Wojciechowski, BS, RHIA, RHIT, CCDS
AHIMA-Approved ICD-10-CM/PCS Trainer
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I may not understand, but per the tip sheet if a doctor suspects a pt has a uti and has a fever and tachycardia 110, that would equal- sirs plus source and codes to Sepsis??? Even if not showing hemodynamic instability???
I have use the attached resource for my own use (it is borrowed from MD Anderson, I found it online)
http://www.mdanderson.org/education-and-research/resources-for-professionals/clinical-tools-and-resources/practice-algorithms/clin-management-sepsis-management-adult-web-algorithm.pdf
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Thank you, Katy!
Vivian
Vivian E. Gannon RN,CCM,CCDS
Clinical Documentation Improvement Coordinator
Chesapeake Regional Medical Center
vivian.gannon@chesapeakeregional.com
Thanks,
Tara, RN, CCDS
Please clarify which, if any, of the following is the most likely etiology of the above symptoms and treatment rendered:
- SIRS (Systemic inflammatory response syndrome based on 2 or more criteria listed below)
- Sepsis (SIRS due to an infection)
- Severe Sepsis (sepsis with organ dysfunction)
- Septic Shock (severe sepsis with hypotension and organ hypoperfusion)
- Sepsis/SIRS due to urinary source (Urosepsis)
- Sepsis/SIRS due to an implanted device (F/C, PICC line, joint prosthesis, etc.)
- Sepsis/SIRS due to a localized infection (cellulitis, pneumonia, UTI, etc.)
- UTI (codeable term for documented urosepsis)
- Localized infection only, without systemic illness (please specify site)
- Bacteremia (abnormal lab finding only, does not indicate systemic illness)
- Other
- Unable to determine
Criteria for SIRS (Systemic Inflammatory Response Syndrome) criteria from Merck Manual:
- Fever > 100.4°F or hypothermia < 96.8°F
- Leukocytosis – WBC > 12,000 or leukopenia, WBC < 4,000, or > 10% bands
- Tachycardia- > 90 beats/minute
- Tachypnea- RR > 20 breaths/minute or PaCO2 > 32mmHg
I teach my doctors to state the diagnosis sepsis and then continue with words "as demonstrated by".... and then write the symptoms using the SIRS criteria. Hope this helps.
Laurie L. Prescott RN, MSN, CCDS
lprescott@morehead.org
Sharon Cole, RN, CCDS
CDI Specialist
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org
http://www.hcpro.com/acdis/details.cfm?topic=WS_ACD_JNL&content_id=288080
Hope this helps!
Melissa Varnavas| Senior Managing Editor
Associate Director|ACDIS
75 Sylvan Street, Suite A-101
Danvers, MA 01923
P 978/406-4711 | www.acdis.org
Mvarnavas@cdiassociation.com