SIRS with and infection
Hi
Can anyone shed some light on SIRS and infection for me. The physcian documented "SIRS with an infection" and also documented UTI. When it was coded the UTI was coded as the PDX and code 995.90 was assigned. Per coding guidelines, SIRS "WITH" and infection should be coded as 038.xx and 995.9x as well as the code for the localized infection. Our coder states the physician has to document is as SIRS "DUE TO" an infection, in order for it to be coded this way. Am I interpreting the guidelines incorrectly? If so, where can I find information about it.
If anyone has some wisdom regarding this it would be great.
Thanks
Renee, RN, CCDS
Can anyone shed some light on SIRS and infection for me. The physcian documented "SIRS with an infection" and also documented UTI. When it was coded the UTI was coded as the PDX and code 995.90 was assigned. Per coding guidelines, SIRS "WITH" and infection should be coded as 038.xx and 995.9x as well as the code for the localized infection. Our coder states the physician has to document is as SIRS "DUE TO" an infection, in order for it to be coded this way. Am I interpreting the guidelines incorrectly? If so, where can I find information about it.
If anyone has some wisdom regarding this it would be great.
Thanks
Renee, RN, CCDS
Comments
I agree with your interpretation.
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
I know our coding auditors are all over our coders regarding opportunity for retro queries .
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
The I-9 Coding Guidelines pg. 16 1) a. (ii) states SIRS generally refers to a systemic response to infection, trauma/burn or other insult (such as cancer) with symptoms including fever, tachycardia, tachypena & leukocytosis. (iii) Sepsis generally refers to SIRS due to infection.
Therefore, in my opinion,it would be coded as sepsis due to UTI when linked : 038.9, 599.0, and 995.9X
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
IMPORTANT: This communication contains information from Hays Medical Center which may be confidential and privileged. If it appears that the communication was addressed or sent to you in error, you may not use or copy this communication or any information contained therein, and you may not disclose this communication or the information contained therein to anyone else. In such circumstances, please notify me immediately by reply email or by telephone. Thank you.
If pt had 'something else' that may cause non-infectious SIRS, such as burns, then I would query. But, if a chart documents SIRS with UTI, Pneumonia, Cellulitis, I do not feel compelled to query by my interpretation of the guidelines as long as no other causes of SIRS are clinically evident.
Guidelines also state:
If the terms sepsis, severe sepsis, or SIRS ARE USED with an underlying infection other than septicemia, such as pneumonia, cellulitis or a nonspecified urinary tract infection, code 038.9 should be assigned first, then code 995.91
If the terms sepsis, severe sepsis, or SIRS are used with an underlying infection other than septicemia, such as pneumonia, cellulitis or a nonspecified urinary tract infection, code 038.9 should be assigned first, then code 995.91, followed by the code for the initial infection. This is because the use of the terms sepsis or SIRS indicates that the patient’s infection has advanced to the point of a systemic infection so the systemic infection should be sequenced before the localized infection. The instructional note under subcategory 995.9 instructs to assign the underlying condition first. Note: the term urosepsis is a nonspecific term. If that is the only term documented then only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism if known.
Portion of Guidelines State:
Sepsis/SIRS with Localized Infection
If the reason for admission is both sepsis, severe sepsis, or SIRS and a localized infection, such as pneumonia or cellulitis, a code for the systemic infection (038.xx, 112.5, etc) should be assigned first, then code 995.91 or 995.92, followed by the code for the localized infection. If the patient is admitted with a localized infection, such as pneumonia, and sepsis/SIRS doesn’t develop until after admission, see guideline I.C.1.b.2.b).
VOLUME 20 FOURTH QUARTER
NUMBER 4 2003, Page 79
Coding of Septicemia, SIRS, Sepsis, Severe Sepsis and Septic Shock
VOLUMES 1 AND 2 NEW/REVISED DIAGNOSIS CODES
Since the creation of the series of codes for systemic inflammatory response syndrome (SIRS), effective October 1, 2002, and the inclusion of the term sepsis under code 995.91, Systemic inflammatory response syndrome due to infectious process without organ dysfunction, effective with the October 1, 2003 update, there have been many questions on the proper coding of infections. The information in this article refers to coding of sepsis in adult, non-gravid patients. Separate codes exist for sepsis complicating pregnancy and in newborns.
If the terms sepsis, severe sepsis, or SIRS are used with an underlying infection other than septicemia, such as pneumonia, cellulitis or a nonspecified urinary tract infection, code 038.9 should be assigned first, then code 995.91, followed by the code for the initial infection. This is because the use of the terms sepsis or SIRS indicates that the patient’s infection has advanced to the point of a systemic infection so the systemic infection should be sequenced before the localized infection. The instructional note under subcategory 995.9 instructs to assign the underlying condition first. Note: the term urosepsis is a nonspecific term. If that is the only term documented then only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism if known.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
038.9
599.0
995.91
Thank you,
Norma T. Brunson, BS, RHIA, CDIP, CCS, CCDS
Regards
Renee, RN, CCDS