Coding of SEVERE Sepsis
Hello, Colleagues: I have a 'polling question' for the group regrading how and when the CODE for Severe Sepsis should be assigned. The code in question is 995.52, Severe Sepsis. Assignment of this code is important as it impacts quality metrics. The Essence of the question is "do you assign this code if Severe Sepsis is noted AND "ONLY" if the conditions listed in the Tabular List under 995.52, indicating the additional acute organ dysfunctions are also docuemnted??
ICD-9-CM Coding Rules applicable to Sepsis
The ICD-9-CM Official Guidelines and Coding Clinic for ICD-9-CM, official advice referable to ICD-9-CM, offer explicit advice regarding code assignment for patients documented to have sepsis and severe sepsis, assuming that the patient has these conditions and that these have been consistently and completely documented by a treating provider.
The ICD-9-CM Index to Diseases classifies sepsis and severe sepsis as follows:
Sepsis (generalized) 995.91
With (emphasis added)
abortion - see Abortion, by type, with sepsis
acute organ dysfunction (emphasis added) 995.92
ectopic pregnancy (see also categories 633.0-633.9) 639.0
molar pregnancy (see also categories 630-632) 639.0
multiple organ dysfunction (emphasis added) (MOD) 995.92
Note that sepsis alone codes to 995.91, sepsis, in the ICD-9-CM Index to Diseases while sepsis with any linked acute organ dysfunction (not failure) codes to 995.92. This requirement to use 995.92 with sepsis and any linked acute organ dysfunction is further elaborated in the ICD-9-CM Official Guidelines that state:
“If a patient has sepsis and an acute organ dysfunction (emphasis added), but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign code 995.92, Severe sepsis. An acute organ dysfunction must be associated with clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.â€
Once an acute organ dysfunction has been lined to sepsis, then the ICD-9-CM Table to Diseases continues to require the use of code 995.92, Severe sepsis, and a code to specify the acute organ dysfunction (emphasis added). The list of organ dysfunctions and failures offered is not exhaustive, given the use of the word “such as†in the use additional code note.
Correlation with Physician Literature
Physician literature corroborates ICD-9-CM in its definition of severe sepsis. The Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012, defines “Severe Sepsis’ as “sepsis-induced tissue hypoperfusion AND/OR organ dysfunction (emphasis added) documented to be due to infection.
Note that a number of these conditions are not in and of themselves organ failures. A patient can have prolonged hypotension but not be in septic shock if there is no evidence of tissue dysoxia on physical examination or manifested by an elevated lactate level. Bilirubin elevations (or jaundice) do not necessarily mean that acute liver failure is present. A platelet count of less than 100,000 does not necessarily mean that the bone marrow has failed or that the patient has disseminated intravascular coagulation. Hypoxemia alone is not acute hypoxemic respiratory failure unless other criteria are met.
As such, since the coding rules allow for severe sepsis to be coded when the provider links an acute organ dysfunction such as these listed above or others that are not listed, such as an acute mental status change or a critical illness neuropathy.
ICD-9-CM Coding Rules applicable to Sepsis
The ICD-9-CM Official Guidelines and Coding Clinic for ICD-9-CM, official advice referable to ICD-9-CM, offer explicit advice regarding code assignment for patients documented to have sepsis and severe sepsis, assuming that the patient has these conditions and that these have been consistently and completely documented by a treating provider.
The ICD-9-CM Index to Diseases classifies sepsis and severe sepsis as follows:
Sepsis (generalized) 995.91
With (emphasis added)
abortion - see Abortion, by type, with sepsis
acute organ dysfunction (emphasis added) 995.92
ectopic pregnancy (see also categories 633.0-633.9) 639.0
molar pregnancy (see also categories 630-632) 639.0
multiple organ dysfunction (emphasis added) (MOD) 995.92
Note that sepsis alone codes to 995.91, sepsis, in the ICD-9-CM Index to Diseases while sepsis with any linked acute organ dysfunction (not failure) codes to 995.92. This requirement to use 995.92 with sepsis and any linked acute organ dysfunction is further elaborated in the ICD-9-CM Official Guidelines that state:
“If a patient has sepsis and an acute organ dysfunction (emphasis added), but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign code 995.92, Severe sepsis. An acute organ dysfunction must be associated with clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.â€
Once an acute organ dysfunction has been lined to sepsis, then the ICD-9-CM Table to Diseases continues to require the use of code 995.92, Severe sepsis, and a code to specify the acute organ dysfunction (emphasis added). The list of organ dysfunctions and failures offered is not exhaustive, given the use of the word “such as†in the use additional code note.
Correlation with Physician Literature
Physician literature corroborates ICD-9-CM in its definition of severe sepsis. The Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012, defines “Severe Sepsis’ as “sepsis-induced tissue hypoperfusion AND/OR organ dysfunction (emphasis added) documented to be due to infection.
Note that a number of these conditions are not in and of themselves organ failures. A patient can have prolonged hypotension but not be in septic shock if there is no evidence of tissue dysoxia on physical examination or manifested by an elevated lactate level. Bilirubin elevations (or jaundice) do not necessarily mean that acute liver failure is present. A platelet count of less than 100,000 does not necessarily mean that the bone marrow has failed or that the patient has disseminated intravascular coagulation. Hypoxemia alone is not acute hypoxemic respiratory failure unless other criteria are met.
As such, since the coding rules allow for severe sepsis to be coded when the provider links an acute organ dysfunction such as these listed above or others that are not listed, such as an acute mental status change or a critical illness neuropathy.