ileus as organ dysfunction for severe sepsis
How do you feel about using ileus as an acute organ dysfunction to support the dx of severe sepsis? We have a CDI consultant who states that this is acceptable. The organ dysfunctions listed in the coding book do not include ileus however the list is prefaced with "use additional code to identify specific acute organ dysfunction such as..." This wording indicates to me that the list is not necessarily all-inclusive.
That said, my own research and reading have not shown a cause-effect relationship between sepsis and ileus and I cannot find an authoritative source that makes me want to jump on this bandwagon.
I would appreciate hearing others' insights and experience.
Judy Riley, RHIT, CCS, AHIMA-Approved ICD-10 Trainer
CDI/Coding Manager
LRGHealthcare
jriley@lrgh.org
THIS MESSAGE IS CONFIDENTIAL.
This e-mail message and any attachments are proprietary and confidential information intended only for the use of the recipient(s) named above. If you are not the intended recipient, you may not print,distribute, or copy this message or any attachments. If you have received this communication in error, please notify the sender by return e-mail and delete this message and any attachments from your computer. Any views or opinions expressed are solely those of the author and do not necessarily represent those of LRGHealthcare.
That said, my own research and reading have not shown a cause-effect relationship between sepsis and ileus and I cannot find an authoritative source that makes me want to jump on this bandwagon.
I would appreciate hearing others' insights and experience.
Judy Riley, RHIT, CCS, AHIMA-Approved ICD-10 Trainer
CDI/Coding Manager
LRGHealthcare
jriley@lrgh.org
THIS MESSAGE IS CONFIDENTIAL.
This e-mail message and any attachments are proprietary and confidential information intended only for the use of the recipient(s) named above. If you are not the intended recipient, you may not print,distribute, or copy this message or any attachments. If you have received this communication in error, please notify the sender by return e-mail and delete this message and any attachments from your computer. Any views or opinions expressed are solely those of the author and do not necessarily represent those of LRGHealthcare.
Comments
I do agree that the 'organ dysfunctions' stated in the code book are NOT all-inclusive...this is only a partial listing. As one example, a type II AMI 2/2 to sepsis is not listed as an acute organ dysfunction associated with Severe Sepsis. Further, the coding conventions do not make a distinction between an organ "failure' and an organ 'dysfunction' and dysfunctions that do not rise to the level may be present in some patients w/ severe sepsis.
I made my notes on this topic prior to the conversion to I-10 guidelines.
"Surviving Sepsis" does include ileus as consequence of sepsis, as below from 2012 publication, p 6, Diagnostic Criteria.
[cid:image003.png@01D13BD9.C8423820]
My current practice and philosophy, modify for implementation of I-10.
* Physician documentation is the basis for all coding. The recognition and management of Severe Sepsis is a difficult task that is the responsibility of physicians.
* Sepsis causing Multiple Organ Dysfunction Syndrome is coded as Severe Sepsis.
* Severe sepsis generally refers to sepsis with associated acute organ dysfunction (e.g., oliguria, hypoxemia, lactic acidosis, altered cerebral function, hypoperfusion, and hypotension).
* Severe sepsis requires additional code(s) for the associated acute organ dysfunction(s)-10. If a patient has sepsis with multiple organ dysfunctions, follow the instructions for coding severe sepsis.
* For patients with documentation of severe sepsis, the code for the systemic infection should be sequenced first, followed by code 995.92, Systemic inflammatory response syndrome due to infectious process with organ dysfunction (Severe Sepsis).
* If it is unclear that the documented organ dysfunction or failure is due to sepsis, then a query should be rendered. With the exception of the term Septic Shock, the physician must clearly link the organ dysfunction to the sepsis.
* Associated organ dysfunctions or failures that are a manifestation of severe sepsis are coded to fully report the complexity and associated severity of illness and risk of mortality of the severe sepsis.
* If a documented acute organ dysfunction implies a more severe illness, if the clinical circumstances warrant it, a concurrent or retrospective communication should be initiated to determine what language best describes the patient's conditions so that appropriate ICD-9-CM codes may be assigned.
ICD-9-CM Official Coding Guidelines
AHA Coding Clinic
If a physician documents SIRS due to an infection and the criteria for sepsis is met, a query to determine if the patient has sepsis is required
- Coding Clinic, 3rd Quarter, 2014, page 4
If a patient meets the criteria for sepsis but the physician hasn't documented it, a query is required
- Coding Clinic, 3rd Quarter, 2014, page 4
If a physician documents sepsis but its clinical validity is questionable, a query is required
- Coding Clinic, 1st Quarter, 2012, page 19
"Severe sepsis is associated with organ dysfunction, hypoperfusion, or hypotension. Hypoperfusion/organ dysfunction may include, but is not limited to lactic acidosis, oliguria, and/or acute alteration in mental status."
- Coding Clinic(r) for ICD-9-CM, 2Q 2000, Volume 17, Number 2, Pages 3-7
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."
Once an acute organ dysfunction has been linked 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.
[cid:image006.jpg@01D13BDB.25920C20]
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. Please refer to Table 2 in this reference outlined below:
[cid:image007.jpg@01D13BDB.25920C20]
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, the coding rules allow for severe sepsis to be coded when the provider links an acute organ dysfunction to 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
Judy
Judy Riley, RHIT, CCS, AHIMA-Approved ICD-10 Trainer
CDI/Coding Manager
LRGHealthcare
jriley@lrgh.org
[cid:image001.jpg@01D13BF7.5A856EB0]
A – Potential Inflammatory Response
SEPSIS
0 Sepsis w/o associated acute organ dysfunction
0 Severe sepsis (causing associated acute organ dysfunction – Complete Section "B".
SIRS
0 SIRS due to infectious process with Sepsis
0 SIRS due to infectious process without Sepsis
0 SIRS due to non-infectious etiology without acute organ dysfunction
0 SIRS due to non-infectious etiology with acute organ dysfunction
No Form of Systemic Illness
0 Bacteremia without sepsis (abnormal lab finding only, does not indicate systemic illness)
0 Localized infection only, without systemic illness (please specify)*
0 Not clinically significant
0 Unable to determine
0 Other diagnosis (please specify)*
Section B - Associated Acute Organ Dysfunction(s)
0 No associated acute organ dysfunction
0 Lactic acidosis
0 Shock
0 Circulatory failure (peripheral)
0 Hypotension, only, w/o shock
0 Acute kidney failure / injury
0 Acute tubular necrosis
0 Acute renal insufficiency
0 Azotemia 0 Oliguria 0 Anuria
0 Acute respiratory failure
0 Acute respiratory distress syndrome (ARDS)
0 Hypoxia 0 Hypercarbia
0 Critical illness myopathy
0 Critical illness polyneuropathy
0 Disseminated intravascular coagulopathy (DIC)
0 Thrombocytopenia 0 Coagulopathy
0 Encephalopathy 0 Coma 0 Acute delirium
0 Acute hepatic failure 0 Shock liver
0 Ileus 0 Jaundice
0 Acute cardiomyopathy
0 Acute myocardial infarction (AMI)
0 Acute heart failure (congestive)
0 Acute demand ischemia
0 Acute coronary syndrome
0 Atrial fibrillation
0 Diabetic ketoacidosis
0 Multiple organ dysfunction syndrome (MODS)
0 Other diagnosis (please specify)*
Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)
A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented.
We, in CDI, deal with the terms 'failure' and 'dsyfuction' in precise ways - As an example, Acute renal FAILURE or Injury does not always mean the organ has failed completely (not making urine). It may mean the organ is dysfunctional. A new creatinine of 2.0 while making urine can be acute renal failure. A creatinine of 3.0 while making urine can be acute renal failure. A creatinine of 4.0 while making urine can be acute renal failure....... And failure to make urine at all is acute renal failure. My point is virtually all patients coded as acute renal FAILURE still have a functional organ making urine.
More importantly, however, severe sepsis only requires organ dysfunction not outright failure. So. You don't need FAILURE to code Severe sepsis, just dysfunction. Reference page 585 of Surviving Sepsis that lists "organ dysfunction(s)" associated with sepsis.
RE: Ileus as a consequence of Sepsis, our CDI practice on this is driven by one of the authors of the Surviving Sepsis Guidelines, 2012: His guidance is that an ileus may be a 'dysfunction', (Not A Failure) that defines Severe Sepsis. Ileus is listed as one of the Organ Dysfunctiona Variables for Sepsis per Surviving Sepsis Guidelines.
[cid:image006.png@01D13C9D.5D0166C0]
[cid:image001.png@01D13C9F.4F4CB9B0]
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 value this site as I find the discussions always improve my critical skills, and I believe that we benefit if/when we discuss issues that are a bit muddy and not settled.
Where I differ per my central philosophy is that the current coding rules do state that acute organ dysfunction that is a consequence permits us to code R65.2x. I view the list of failures per the guidelines in the official coding references as examples of dysfunctions that are all failures, but not inclusive of all diagnoses that are dysfunctions and that are the consequences of severe sepsis that may permit coding of R65.2X.
So, ileus aside, what about other dysfunctions clearly stated as a consequence of sepsis – are these to be considered adequate documentation to assign a secondary code for Severe Sepsis? We all know the coding guidelines are not always congruent w/ clinical reality – that can be both confusing and frustrating. However, we need to consider the guidelines as we consider this discussion.
Example: (Lactate Above Normal Limits is stated as one variable used to define Severe Sepsis per SS 2012, yet there is not a code for that statement – one could ‘query’ for intent, and if the patients is acidotic as a consequence of uncompensated elevated lactic levels, consider coding ‘lactic acidosis’ – but, this is not an organ failure.) So, if our charts document severe sepsis as manifested by lactate of 5.0 and the record further documents this is acidosis, do we assign the secondary code for Severe Sepsis, even though this is not an organ failure? (I know many consider elevated lactate ‘shock’, but that is another matter).
[cid:image002.png@01D14160.E7176130]
There is universal agreement that overt failures (ATN, Acute Respiratory Failure) as a consequence of sepsis are coded as ‘severe sepsis’ when documentation is clear. If the intent of the Cooperating Parties is that overt failures only are required in order to assign a secondary code for Severe Sepsis, but not dysfunction, the Guidelines need to be revisited and modified to that effect.
I have actually written AHA Coding Clinic on this issue, and copyright issues do not permit me to share the response..however, in brief, AHA stated to ‘follow the current guidelines when assigning the code(s) for Severe Sepsis….which was really not a helpful response given I had asked very specific questions in my inquiry. I seem to share concerns w/ others that a revisit or clarification may be helpful visa vie the Coordination & Maintenance Committee?
[cid:image001.png@01D1415F.EA2DE570]
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