According to the new core measures for sepsis, a lactate > 2 is evidence of severe sepsis and a lactate > 4 is evidence of septic shock.
As far as what I would put on queries, if there are associated clinical signs of sepsis, I would just include the lactate level elevated above facility normals, in the sepsis query.
You may find this useful: This table does NOT represent the coding rules for any condition, rather is a concise compilation of some indications of the condition.
Anna Rozhkovskaya, RHIT, CCS, CCS-P Manager, Clinical Documentation Improvement Memorial Healthcare System Health Information Management Department 2990 Executive Way, Miramar, Fl 33025 (954)276-9957 Office (954)265-6974 Mobile (954)441-9459 Fax
I neglected to earlier provide definitions we use for this topic. I am aware SIRS no longer codes directly to sepsis.
Definitions:
· SIRS – Systemic Inflammatory Response Syndrome – Two or more of the following: Body temperature >38 ◦C or 90 beats/min; Respiratory rate >20 breaths/min or hyperventilation with a PaCO2 less than 32 mmHg; White blood cell count >12000/mm3, 10% immature neutrophils.2
· Bacteremia – Presence of viable bacteria in the blood.2
· Sepsis – Infection plus systemic manifestations of infection1. SIRS with a confirmed infectious process.2
· Severe Sepsis – acute organ dysfunction or tissue hypoperfusion secondary to infection1
· Septic Shock – severe sepsis plus hypotension not reversed with adequate fluid resuscitation or blood lactate >4 mmol/L.1
· Hypotension – sepsis-induced hypotension defined as a systolic blood pressure (SBP) 2- to 3-fold) from baseline
Less than 0.5 ml/kg per hour for more than 12 hours
3c
Increase in serum creatinine to more than 300% (> 3-fold) from baseline (or serum creatinine of more than or equal to 4.0 mg/dl [≥ 354 μmol/l] with an acute increase of at least 0.5 mg/dl [44 μmol/l])
Less than 0.3 ml/kg per hour for 24 hours or anuria for 12 hours
Modified from RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease) criteria. Only one criterion (creatinine or urine output) has to be fulfilled to qualify for a stage. b200% to 300% increase = 2- to 3-fold increase. cGiven wide variation in indications and timing of initiation of renal replacement therapy (RRT), individuals who receive RRT are considered to have met the criteria for stage 3 irrespective of the stage they are in at the time of RRT.
· Acute renal insufficiency - The same definition as acute kidney injury, yet the rise of creatinine or fall of urine output fails to meet the acute kidney injury criteria. (Srisawat N., et.al. Modern Classification of Acute Kidney Injury. Blood Purification 2010;29:300–307.) · Urosepsis: Defined only as a “simple” UTI. (AHA – Coding Clinic)
We use elevated lactate as only one possible indicator of sepsis, bearing in mind that multiple clinical issues can elevated lactate, and also bearing in mind that pts with normal lactate may be septic. We built our local definitions and query forms for Sepsis with input from a physician that is a signatory to the 2012 Surviving Sepsis Guidelines.
I certainly agree to issue a query based solely on one lab value would not be Best Practice; but, I must also state that all of our clinical advisors and ICU staff believe elevated lactate is a very useful prognostic tool.
If a pt meets criteria for Sepsis consistent with the accepted criteria in Surviving Sepsis 2012, we have been advised to issue a query to either confirm the potential condition and/or ascertain if any sepsis, if present, is causing any acute organ dysfunction (Severe Sepsis) given the coding of Severe Sepsis impacts multiple quality metrics and mortality scores.
The queries as issued in a 'neutral fashion' w/o any expectations of a particular response; I'd hope that no physician would be unduly 'influenced' by an invalid query given the responding MD is the expert visa vie recognition of clinical terms.
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
Certainly this is one of the most complicated (and controversial) issues in our current scope of practice. The more we read about lactate levels, AKI< SIRs without Sepsis, and so forth, the better in that we need to be have conversations with clinicians that are compliant AND congruent w/ current and generally accepted Best Practice. It is certainly no small task, but that is what makes this endeavor challenging and rewarding.
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
Comments
As far as what I would put on queries, if there are associated clinical signs of sepsis, I would just include the lactate level elevated above facility normals, in the sepsis query.
This is a great little lactate FAQ from an EM physician.
http://emcrit.org/wp-content/uploads/lactate-faq.pdf
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System
Paul Evans
Sent from iPad2
[cid:image001.png@01D12B50.D7A86350]
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
Thank you so much for the information!! I really appreciate the help!!
Thank you very much for this resource! I will definitely use it!!
Thanks, Dr. Gold!
Anna Rozhkovskaya, RHIT, CCS, CCS-P
Manager, Clinical Documentation Improvement
Memorial Healthcare System
Health Information Management Department
2990 Executive Way, Miramar, Fl 33025
(954)276-9957 Office
(954)265-6974 Mobile
(954)441-9459 Fax
Definitions:
· SIRS – Systemic Inflammatory Response Syndrome – Two or more of the following: Body temperature >38 ◦C or 90 beats/min; Respiratory rate >20 breaths/min or hyperventilation with a PaCO2 less than 32 mmHg; White blood cell count >12000/mm3, 10% immature neutrophils.2
· Bacteremia – Presence of viable bacteria in the blood.2
· Sepsis – Infection plus systemic manifestations of infection1. SIRS with a confirmed infectious process.2
· Severe Sepsis – acute organ dysfunction or tissue hypoperfusion secondary to infection1
· Septic Shock – severe sepsis plus hypotension not reversed with adequate fluid resuscitation or blood lactate >4 mmol/L.1
· Hypotension – sepsis-induced hypotension defined as a systolic blood pressure (SBP) 2- to 3-fold) from baseline
Less than 0.5 ml/kg per hour for more than 12 hours
3c
Increase in serum creatinine to more than 300% (> 3-fold) from baseline (or serum creatinine of more than or equal to 4.0 mg/dl [≥ 354 μmol/l] with an acute increase of at least 0.5 mg/dl [44 μmol/l])
Less than 0.3 ml/kg per hour for 24 hours or anuria for 12 hours
Modified from RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease) criteria. Only one criterion (creatinine or urine output) has to be fulfilled to qualify for a stage. b200% to 300% increase = 2- to 3-fold increase. cGiven wide variation in indications and timing of initiation of renal replacement therapy (RRT), individuals who receive RRT are considered to have met the criteria for stage 3 irrespective of the stage they are in at the time of RRT.
· Acute renal insufficiency - The same definition as acute kidney injury, yet the rise of creatinine or fall of urine output fails to meet the acute kidney injury criteria. (Srisawat N., et.al. Modern Classification of Acute Kidney Injury. Blood Purification 2010;29:300–307.)
· Urosepsis: Defined only as a “simple” UTI. (AHA – Coding Clinic)
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 certainly agree to issue a query based solely on one lab value would not be Best Practice; but, I must also state that all of our clinical advisors and ICU staff believe elevated lactate is a very useful prognostic tool.
If a pt meets criteria for Sepsis consistent with the accepted criteria in Surviving Sepsis 2012, we have been advised to issue a query to either confirm the potential condition and/or ascertain if any sepsis, if present, is causing any acute organ dysfunction (Severe Sepsis) given the coding of Severe Sepsis impacts multiple quality metrics and mortality scores.
The queries as issued in a 'neutral fashion' w/o any expectations of a particular response; I'd hope that no physician would be unduly 'influenced' by an invalid query given the responding MD is the expert visa vie recognition of clinical terms.
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
Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)
Certainly this is one of the most complicated (and controversial) issues in our current scope of practice. The more we read about lactate levels, AKI< SIRs without Sepsis, and so forth, the better in that we need to be have conversations with clinicians that are compliant AND congruent w/ current and generally accepted Best Practice. It is certainly no small task, but that is what makes this endeavor challenging and rewarding.
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