RE: SIRS indicators Specifications Manual
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Agree with Paul.
Out of curiosity I found the reference in the Manual. Please see highlight=
ed area.
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 11:34 AM
To: Salinas, Sharon
Subject: RE:[cdi_talk] SIRS indicators
Are we referring to authority to issue quality measures for patients w/ Sep=
sis and/or 'authority' to mandate when the condition is diagnosed by a clin=
ician?
As far as institution of Core Measures under the Pay For Performance Progra=
m, CMS has authority to mandate required PROCESS measures for patients w/=
Sepsis. To my knowledge, CMS, nor any other 3rd party, does not have au=
thority to mandate how and when the condition is recognized or diagnosed.
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
[cid:image001.jpg@01CE983E.025F5700]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 11:28 AM
To: Evans, Paul
Subject: RE:[cdi_talk] SIRS indicators
CMS
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 2:24 PM
To: Mary Snook
Subject: RE:[cdi_talk] SIRS indicators
I have a question please? Under whose authority is the Sepsis criteria goin=
g to change? Where do we look to find these new criteria that are supposed =
to change due to it being a core measure? Thanks
Jamie
Jamie Dugan RN, CCDS
Clinical Documentation Improvement Specialist
3563 Philips Highway, Suite #106
Jacksonville, Florida 32207
Office: 904-202-4345
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 2:19 PM
To: Dugan, Jamie G
Subject: RE:[cdi_talk] SIRS indicators
We have a new Core Measure rolling out on 10/1/15-yes the same day as ICD 1=
0 for sepsis, severe sepsis and septic shock. It will cast a wide net for =
Sepsis documentation , coding and capturing as the criteria are going to ch=
ange. New query to be developed and consideration for additional CDI staff=
-(one maybe). Scrambling are we. Notification from CMS was in a six month =
time frame!
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 11:46 AM
To: Mary Snook
Subject: RE:[cdi_talk] SIRS indicators
Could someone please post a link to the CMS guidelines for reporting sepsis?
I hope this won't devolve into a situation whereby we are denied reporting =
sepsis in patients that are clearly stated as having sepsis, based upon the=
judgement of the clinical staff, only to have someone off-site 'deny' the =
diagnosis because the temperature did not meet the "CMS" Criteria? As we a=
ll know, there are many, many variables impacting an individual's physiolog=
ical response to Sepsis.
I am obviously not a clinical expert on the topic, but our physicians plac=
e a lot of faith in the International Guidelines regarding Sepsis - but non=
e in the diagnostic ability of CMS.
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
[cid:image001.jpg@01CE983E.025F5700]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 7:23 AM
To: Evans, Paul
Subject: [cdi_talk] SIRS indicators
Good morning. Currently we are working on changing our SIRS/SEPSIS query to=
reflect upcoming changes in I-10 for these diagnosis. On our current query=
, we have the SIRS indicators with the temp of 38.0. Our SEPSIS coordinator=
informed us last week that starting June 15 the temperature for our screen=
ing tools for our sepsis initiative through the ED and with sepsis screenin=
g tools (for the floors) was being changed from 38.0 to 38.3 per recommenda=
tions from the new CMS guidelines for reporting sepsis.
Does anyone else currently use 38.0 as was suggested years ago by our consu=
ltant (from Merck), or are you changing to reflect the trend for the higher=
temp??
TIA
Juli
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
755-8426 (work)
786-2677 (cell)
"No Limit to Better......"
[CCDS_pin_1inch]
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--_000_7187D860E0217F48A5EEEFDDFDE31ACD2374A5BFMAILbarlowcom_
Content-Type: text/plain; charset="us-ascii"
Content-Transfer-Encoding: quoted-printable
Agree with Paul.
Out of curiosity I found the reference in the Manual. Please see highlight=
ed area.
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 11:34 AM
To: Salinas, Sharon
Subject: RE:[cdi_talk] SIRS indicators
Are we referring to authority to issue quality measures for patients w/ Sep=
sis and/or 'authority' to mandate when the condition is diagnosed by a clin=
ician?
As far as institution of Core Measures under the Pay For Performance Progra=
m, CMS has authority to mandate required PROCESS measures for patients w/=
Sepsis. To my knowledge, CMS, nor any other 3rd party, does not have au=
thority to mandate how and when the condition is recognized or diagnosed.
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
[cid:image001.jpg@01CE983E.025F5700]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 11:28 AM
To: Evans, Paul
Subject: RE:[cdi_talk] SIRS indicators
CMS
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 2:24 PM
To: Mary Snook
Subject: RE:[cdi_talk] SIRS indicators
I have a question please? Under whose authority is the Sepsis criteria goin=
g to change? Where do we look to find these new criteria that are supposed =
to change due to it being a core measure? Thanks
Jamie
Jamie Dugan RN, CCDS
Clinical Documentation Improvement Specialist
3563 Philips Highway, Suite #106
Jacksonville, Florida 32207
Office: 904-202-4345
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 2:19 PM
To: Dugan, Jamie G
Subject: RE:[cdi_talk] SIRS indicators
We have a new Core Measure rolling out on 10/1/15-yes the same day as ICD 1=
0 for sepsis, severe sepsis and septic shock. It will cast a wide net for =
Sepsis documentation , coding and capturing as the criteria are going to ch=
ange. New query to be developed and consideration for additional CDI staff=
-(one maybe). Scrambling are we. Notification from CMS was in a six month =
time frame!
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 11:46 AM
To: Mary Snook
Subject: RE:[cdi_talk] SIRS indicators
Could someone please post a link to the CMS guidelines for reporting sepsis?
I hope this won't devolve into a situation whereby we are denied reporting =
sepsis in patients that are clearly stated as having sepsis, based upon the=
judgement of the clinical staff, only to have someone off-site 'deny' the =
diagnosis because the temperature did not meet the "CMS" Criteria? As we a=
ll know, there are many, many variables impacting an individual's physiolog=
ical response to Sepsis.
I am obviously not a clinical expert on the topic, but our physicians plac=
e a lot of faith in the International Guidelines regarding Sepsis - but non=
e in the diagnostic ability of CMS.
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
[cid:image001.jpg@01CE983E.025F5700]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 7:23 AM
To: Evans, Paul
Subject: [cdi_talk] SIRS indicators
Good morning. Currently we are working on changing our SIRS/SEPSIS query to=
reflect upcoming changes in I-10 for these diagnosis. On our current query=
, we have the SIRS indicators with the temp of 38.0. Our SEPSIS coordinator=
informed us last week that starting June 15 the temperature for our screen=
ing tools for our sepsis initiative through the ED and with sepsis screenin=
g tools (for the floors) was being changed from 38.0 to 38.3 per recommenda=
tions from the new CMS guidelines for reporting sepsis.
Does anyone else currently use 38.0 as was suggested years ago by our consu=
ltant (from Merck), or are you changing to reflect the trend for the higher=
temp??
TIA
Juli
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
755-8426 (work)
786-2677 (cell)
"No Limit to Better......"
[CCDS_pin_1inch]
________________________________
Regional Health is an integrated health care system with the purpose of hel=
ping patients and communities live well.
Note: The information contained in this message, including any attachments,=
may be privileged, confidential, or protected from disclosure under state =
or federal laws . If the reader of this message is not the intended recipie=
nt, or an employee or agent responsible for delivering this message to the =
intended recipient, you are hereby notified that any dissemination, distrib=
ution, or copying of this communication is strictly prohibited. If you have=
received this communication in error, please notify the Sender immediately=
by a "reply to sender only" message and destroy all electronic or paper co=
pies of the communication, including any attachments.
---
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---
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ource.
You are receiving this message as a member of CDI Talk as: snook@fmchealth.=
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---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulat=
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ource.
You are receiving this message as a member of CDI Talk as: jamie.dugan@bmcj=
ax.com
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-13693660.db184642493d9bc34c466e767047cc22@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Fairfield Medical Center
People you know. Care you trust.
"Confidentiality Notice: This email message, including any attachments is f=
or the sole use of the intended recipient(s) and may contain confidential a=
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________________________________
NOTICE: This message is confidential, intended for the named recipient(s) a=
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recipient(s) is not a waiver of any applicable privilege. Thank you in adv=
ance for your compliance with this notice.
---
CDI Talk is offered for networking purposes. For official rules and regulat=
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You are receiving this message as a member of CDI Talk as: snook@fmchealth.=
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---
CDI Talk is offered for networking purposes. For official rules and regulat=
ions related to documentation and coding, please refer to your regulatory s=
ource.
You are receiving this message as a member of CDI Talk as: evanspx@sutterhe=
alth.org
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-12940161.4b24e9352adc7dfa247d8332246d4e2a@hcprotalk.com
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Fairfield Medical Center
People you know. Care you trust.
"Confidentiality Notice: This email message, including any attachments is f=
or the sole use of the intended recipient(s) and may contain confidential a=
nd privileged information. Any unauthorized review; use; disclosure or dist=
ribution is prohibited. If you are not the intended recipient, please conta=
ct the sender by reply e-mail and destroy all copies of the original messag=
e."
---
CDI Talk is offered for networking purposes. For official rules and regulat=
ions related to documentation and coding, please refer to your regulatory s=
ource.
You are receiving this message as a member of CDI Talk as: ssalinas@barlow2=
000.org
If you would like to be removed from CDI Talk, please send a blank email to
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--_000_7187D860E0217F48A5EEEFDDFDE31ACD2374A5BFMAILbarlowcom_
Content-Type: text/html; charset="us-ascii"
Content-Transfer-Encoding: quoted-printable
Agree with Paul.
=
Out of curiosity I found=
the reference in the Manual. Please see highlighted area.=
=
Sharon Salinas, CCS=
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
=
From: CDI Talk=
[mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 11:34 AM
To: Salinas, Sharon
Subject: RE:[cdi_talk] SIRS indicators
Are w=
e referring to authority to issue quality measures for patients w/ Sepsis a=
nd/or ‘authority’ to mandate when the condition is diagnosed by=
a clinician?
=
=
As fa=
r as institution of Core Measures under the Pay For Performance Program, CM=
S has authority to mandate required PROCESS measures for patien=
ts w/ Sepsis. To my knowledge, CMS, nor any
other 3rd party, does not have authority to mandate how and whe=
n the condition is recognized or diagnosed.
=
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation &=
amp; Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107=
Cell: 415.412.9421
=
From: CDI Talk=
[mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 11:28 AM
To: Evans, Paul
Subject: RE:[cdi_talk] SIRS indicators
CMS
Mary L. Snook RN-BC
Clinical Documentation=
Improvement Specialist
Fairfield Medical Cent=
er
740-689-4443
From: CDI Talk=
[mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 2:24 PM
To: Mary Snook
Subject: RE:[cdi_talk] SIRS indicators
I have a question please=
? Under whose authority is the Sepsis criteria going to change? Where do we=
look to find these new criteria that are supposed to change due to it bein=
g a core measure? Thanks
Jamie
=
Jamie Dugan RN, CCDS
Clinical Documentation Im=
provement Specialist
3563 Philips Highway, Sui=
te #106
Jacksonville, Florida&nbs=
p; 32207
Office: 904-202-4345=
=
From: CDI Talk=
[mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 2:19 PM
To: Dugan, Jamie G
Subject: RE:[cdi_talk] SIRS indicators
We have a new Core Mea=
sure rolling out on 10/1/15-yes the same day as ICD 10 for sepsis, severe s=
epsis and septic shock. It will cast a wide net for Sepsis documentat=
ion , coding and capturing as the criteria
are going to change. New query to be developed and consideration for=
additional CDI staff-(one maybe). Scrambling are we. Notification fr=
om CMS was in a six month time frame!
Mary L. Snook RN-BC
Clinical Documentation=
Improvement Specialist
Fairfield Medical Cent=
er
740-689-4443
From: CDI Talk
[mailto:cdi_talk@hcprota=
lk.com]
Sent: Wednesday, June 24, 2015 11:46 AM
To: Mary Snook
Subject: RE:[cdi_talk] SIRS indicators
Could=
someone please post a link to the CMS guidelines for reporting sepsis?&nbs=
p;
=
=
=
I hop=
e this won’t devolve into a situation whereby we are denied reporting=
sepsis in patients that are clearly stated as having sepsis, based upon th=
e judgement of the clinical staff, only to
have someone off-site ‘deny’ the diagnosis because the tempera=
ture did not meet the “CMS” Criteria? As we all know, the=
re are many, many variables impacting an individual’s physiological r=
esponse to Sepsis.
=
I am =
obviously not a clinical expert on the topic, but our physicians plac=
e a lot of faith in the International Guidelines regarding Sepsis – b=
ut none in the diagnostic ability of CMS.
=
Paul
=
=
=
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation &=
amp; Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107=
Cell: 415.412.9421
=
From: CDI Talk=
[mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 24, 2015 7:23 AM
To: Evans, Paul
Subject: [cdi_talk] SIRS indicators
Good morning. Currently we are working on changing o=
ur SIRS/SEPSIS query to reflect upcoming changes in I-10 for these diagnosi=
s. On our current query, we have the SIRS indicators with the temp of 38.0.=
Our SEPSIS coordinator informed us
last week that starting June 15 the temperature for our screening tools fo=
r our sepsis initiative through the ED and with sepsis screening tools (for=
the floors) was being changed from 38.0 to 38.3 per recommendations from t=
he new CMS guidelines for reporting
sepsis.
Does anyone else currently use 38.0 as was suggested=
years ago by our consultant (from Merck), or are you changing to reflect t=
he trend for the higher temp??
TIA
Juli
Juli Bovard RN CCDS
Certified Clinical Documentation Speci=
alist
Clinical Effectiveness/Clinical Qualit=
y
Rapid City Regional Hospital
755-8426 (work)
786-2677 (cell)
"No Limit to Better......"
Regional Health is an integrated hea=
lth care system with the purpose of helping patients and communities live w=
ell.
Note: The information contained in this message, including any attachments,=
may be privileged, confidential, or protected from disclosure under state =
or federal laws . If the reader of this message is not the intended recipie=
nt, or an employee or agent responsible
for delivering this message to the intended recipient, you are hereby noti=
fied that any dissemination, distribution, or copying of this communication=
is strictly prohibited. If you have received this communication in error, =
please notify the Sender immediately
by a "reply to sender only" message and destroy all electronic o=
r paper copies of the communication, including any attachments.
&nbs=
p; ---
CDI Talk is offered for networking purposes. For official rules and re=
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Comments
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
Exclusion Guidelines for Abstraction:
1. * Septic
2. * Bacteremia
3. * Septicemia
4. * Possibly septic
Bacteremia is not septicemia or Sepsis.
This list is not complete:
c. Organ dysfunction, evidenced by any one of the following: i. Systolic blood pressure (SBP) < 90, or mean arterial pressure < 65, or a systolic blood pressure decrease of more than 40 mmHg from the last previously recorded SBP considered normal for that specific patient
ii. Creatinine > 2.0, or urine output < 0.5 mL/kg/hour for 2 hours
iii. Bilirubin > 2 mg/dL (34.2 mmol/L)
iv. Platelet count < 100,000
v. INR > 1.5 or aPTT > 60 sec
vi. Lactate > 2 mmol/L (18.0 mg/dL)
What about Encephalopathy, Acute Respiratory Failure, or a Type II Acute MI 2/2 Sepsis?
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
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