Coding Severe Sepsis

jwright@chmed.org

Do your coders code “Sepsis and Severe Sepsis” when  “Sepsis” is documented with organ failure?

Example of documentation: “Sepsis d/t UTI with Acute Renal Failure due to dehydration and sepsis”.

Can they code  Sepsis, Severe Sepsis and Acute Renal Failure or does the provider need to be queried for documentation of the "Severe Sepsis"?

jackietouch@aol.com

I work in a children's hospital, so may have a different perspective with this example because we base our sepsis criteria on the pediatric guidelines developed in 2005 (see below for reference). With the example given above, coders would capture sepsis and AKI. We would not query for severe sepsis because only one organ system is affected and per pediatric guidelines, unless the child has respiratory or cardiovascular failure, there must be 2 organ systems affected.  

I am not sure if the same criteria (need for 2 organ dysfunctions) holds true for the adult population when using previous sepsis criteria. When we review patients >18 years of age, we would not capture severe sepsis nor query for it as we apply the Sepsis 3 criteria to this population.

Hope this helps,
Jackie Touch, MSN, RN, CCM



 Reference: Brahm Goldstein, MD; Brett Giroir, MD; Adrienne Randolph, MD; and the Members of the International Consensus Conference on Pediatric Sepsis (2005).  International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics.  Pediatric Critical Care Medicine, 6 (1), 2-8.

guerri

A link between sepsis and the organ failure is needed to capture R65.20. Refer to the below link page 20.

https://www.cms.gov/medicare/coding/icd10/downloads/2016-icd-10-cm-guidelines.pdf

Based on the quoted example you provided, yes that would meet criteria for severe sepsis.

Richard Guerzon, RN, CCS, CCDS

jwright@chmed.org

Thanks for the input above.  I know the coding clinics states coders can code the "Severe Sepsis" in the scenario  I explained but I guess what I am wondering is if places do code "Severe Sepsis" without a provider being queried to see if they agree. Any takers on this????

jwright@chmed.org

Christina,
So does that mean you would code Severe Sepsis without it being stated by the provider???

Amber

evanspx@sutterhealth.org

Per Guidelines, one may code Severe Sepsis IF:

Septic Shock is documented

Sepsis is stated as causing an associated acute organ dysfunction

The term Severe Sepsis is documented;  Best Practice would  be to ask for the specific acute organ dysfunction

If an acute organ dysfunction is present,  but the it is not clear if this is 2/2 sepsis, a query is required.

Paul Evans, RHIA, CCDS

evanspx@sutterhealth.org

Example of documentation: “Sepsis d/t UTI with Acute Renal Failure due to dehydration and sepsis”.

ARF in this question is documented as 2/2 sepsis. Per published guidelines, this is coded as Severe Sepsis as the sepsis has caused an 'acute organ dysfunction'.

See ICD-10 Guidelines, which I can't paste here, but which do address this issue.

Paul Evans, RHIA, CCDS

AngeliqueDaigle@yahoo.com

Amber, your documentation sample allows for coding of severe sepsis, because the physician has linked the organ failure to the sepsis. "ARF due to dehydration and sepsis"

Example of documentation: “Sepsis d/t UTI with Acute Renal Failure due to dehydration and sepsis”.

Below is the coding guideline showing when you can code "severe sepsis"

If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2, Severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider

Hope this helps.

Angelique Daigle BSN, RN, CCDS

Angelique.Daigle@stjoeshealth.org

jwright@chmed.org

Thank you to all! This is exactly what I was looking for!

cabark1019

If I could ask additionally...If the record states Sepsis due to UTI, then the physician writes acute metabolic encephalopathy due to UTI, can you assume severe sepsis, since the UTI is linked to the sepsis?

thomasrj@sutterhealth.org

cabark1019 said:

If I could ask additionally...If the record states Sepsis due to UTI, then the physician writes acute metabolic encephalopathy due to UTI, can you assume severe sepsis, since the UTI is linked to the sepsis?

I would query provider for the potential third association.  I cannot trust my imagination to exhaust the possibilities of {A:B & A:C therefore B:C?} but I'm sure it is possible in some clinical scenario for the two conditions (associated with UTI) to be unassociated.  Upon that ambiguity hangs our CDI livelihood.