Infection with SIRS, no sepsis

patrn93@yahoo.compatrn93@yahoo.com
in CDI Talk Archive
Has anyone seen this type of documentation? We have at our hospital and we are having a debate on the correct way to code this and/or address the physicians. Some say we should only code the infection (UTI, pneumonia, etc) since the physician documented no sepsis. Some say we should code the infection with the noninfectious SIRS code 995.90.

Coding guidelines say when infection with SIRS is documented - code 038.x (sepsis), infection, & 995.9x (SIRS), but when the physician states 'no sepsis' - then what do we do???

Thoughts?

Comments

  • annnd2009@gmail.comannnd2009@gmail.com
    edited May 2016
    I think it's an education thing. Infection with 2 of 4 criteria is
    SEPSIS. Maybe could get them to say sepsis with unknown source. 1/3
    of all sepsis cases don't actually identify the source but if there us
    suspected infection and 2 criteria that is definition of sepsis.

    That is my understanding.
    Ann
  • robert.hodges2robert.hodges2
    edited May 2016
    If A provider documents "no sepsis", that means I wouldn't query because they have addressed that question. I also don't think you can code SIRS unless the provider documents SIRS. You can only code the infection.



    It does sound like a query opportunity to me to ask for the significance of any symptoms associated with the infection and include SIRS as one of the options if the symptoms are related to the infection. Back to that "Cause and Effect" query or even a "signs and symptoms" query. I would proceed with caution though to ensure the query is not leading.



    Robert



    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov


    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Have not seen the terminology and it seem contradictory to current (conventional) terminology.

    Sometimes see the terminology SIRS not due to infectious process, such as due to trauma or burns, and that can be coded easily.



    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

  • Unknown
    edited May 2016
    We have this same issue! Some Docs will even write SIRS due to X infection no sepsis present. They are clearly just misinformed on their terminology and definitions. Rather than query, we do education that focuses on sepsis, SIRS, etc. and teach it based on the latest criteria and research I can find. Education works but it is a slow process especially in a large teaching Hospital.
    -Jane

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I would address this as a "conflicting documentation" issue. If I am understanding this correctly, we have documentation of SIRS + Infection. I am assuming that the MD has explicitly linked these two (SIRS and infection). This, per coding guidelines, should code out to sepsis. However, we now have "no sepsis" documented as well.
    I would place a query stating the conflicting documentation and providing definitions for SIRS, sepsis, etc. I would ask which dx is most appropriate and give the relevant options including unable to determine and other and present it to the doc. If possible, I would probably try to contact the MD directly on this one as it may be confusing and it’s a great education opportunity.

    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

  • mdomineseymdominesey
    edited May 2016
    I have had more than one physician inform me that there is no sepsis unless there is hypotension (shock) and bacteremia. I too have had to do education about sepsis because often I see an infection AND pressors and NO diagnosis of sepsis OR septic shock!

    Attached is my "SIRS" criteria query which gives a step-wise framework to defining Sepsis and then getting the most specific diagnosis.

    Mark




    We have this same issue! Some Docs will even write SIRS due to X infection no sepsis present. They are clearly just misinformed on their terminology and definitions. Rather than query, we do education that focuses on sepsis, SIRS, etc. and teach it based on the latest criteria and research I can find. Education works but it is a slow process especially in a large teaching Hospital.

    -Jane
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes, the MD's are often unclear on the definition. We do not have an institutional definition/policy but I routinely "borrow" MD Andersons for reference with the MD's. It seems to make sense for them. It does include the management piece as well as the definitions, but I am focused on the definition part.

    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
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    One more thing :), it's so interesting Mark, because our MD's often talk about hypotension as an indicator of SIRS/Sepsis too. And the resources I have looked at that provide definitions (not just MDAnderson) do NOT include hypotension as an indicator for SIRS/Sepsis. Hypotension is an indicator for septic shock.

    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
  • mdomineseymdominesey
    edited May 2016
    Katy,

    I have used the MD Anderson flowsheet for education, but I never noticed the typo before on it about "90 breaths a minute" under "Heart Rate". Is it even possible to breathe 90 x a minute? :)



  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Ha! I have never noticed that before either!

    I think it's pretty tough for the heart to breathe at any rate :)

    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


  • annnd2009@gmail.comannnd2009@gmail.com
    edited May 2016
    I get it cause that was what I felt defined sepsis as well. When I
    worked in ICUs. We called our patients septic when they infancy has
    septic shock, it's just the more advanced term on a continuum.
    Ann

Sign In or Register to comment.