Sepsis and Negative blood cultures

jillian.bisbe

We recently received a RAC denial for Sepsis pdx with the following rationale: Documentation is conflicting. While the attending documents sepsis, the ID specialist does not, clearly stating No bacteremia. They are citing this coding guideline:

(i) Negative or inconclusive blood cultures and sepsis

Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition; however, the provider should be queried.

I am going to fight the denial, however, this brings up a question I would like to ask: Do you query to validate sepsis with negative blood cultures?

Seems like a frivolous coding guideline when you can have sepsis without positive blood cultures. Love to hear everyone's thoughts!

evanspx@sutterhealth.org

Since positive blood cultures are NOT required to establish the diagnosis, we don’t ‘validate’ every instance in which sepsis is stated and meets our clinical criteria , but the culters are negative.  IMO, this would be entirely innaproate and the Medical Staff would impeach any CDI professional engaging in this practice.  Very, very few of our Sepsis patients yield a + B/C.  The validation we perform is based on the definition embraced by or clinical experts.  It is also possible for a person to have + B/C, and be bacteremic, but not clinally have sepsis; so, the logic used by the RAC is faulty IMO.


On phone, excuse typos, etc
Paul

erica.remer

Only around 30% of BCx are positive in sepsis. Now, there may be an element of capturing patient who are not really septic in this cohort, but the point is that blood cultures do not need to be positive to diagnose sepsis which is supported in the sentinel articles. I agree the guideline is excessive and following it will result in a lot of irritated clinicians. I think sepsis clinical validation queries should be at the discretion of the reviewers. The presumed or confirmed infection should be documented; the patient should be sicker than the average patient with that infection; there needs to be organ dysfunction; documentation should detail clinical support for the diagnosis and verbiage to get R65.2-; remember to attend to core measures.

morris-jeff@CooperHealth.edu

You might could use this coding clinic to help with denial letter

Septicemia with negative blood cultures

ICD-9-CM Coding Clinic, Second Quarter 2000 Page: 5 Effective with discharges: July 1, 2000

Related Information

Septicemia diagnosis with negative blood cultures

Frequently, a patient is suspected of having septicemia and is treated for the condition even though the blood cultures may not be supportive.

Although blood is usually drawn for culturing during the initial work-up, treatment must be started quickly, often before the results of the culture are known. Even when a patient shows clinical evidence of septicemia, the blood culture may be negative owing to the difficulty of culturing certain organisms from blood, the effects of growth-inhibitory factors in the blood, or the initiation of specific antibiotic therapy before laboratory test samples were taken. Negative or inconclusive blood cultures do not preclude a diagnosis of septicemia in patients with clinical evidence of the condition.

Most septicemias are classified to category 038, with fourth and fifth digits indicating the responsible organism. Staphylococcal septicemia uses the fifth digit to indicate that the infection is due to either staphylococcus aureus (038.11) or other specified type of staphylococcus (038.19). Some are classified to another organism, such as disseminated candidiasis (112.5) and herpetic septicemia (054.5). Organisms are sometimes transferred to other tissue, where they may seed infection in another site and lead to such conditions as arteritis, meningitis, and pyelonephritis.

I think this is a classic example of auditors doing what they do best...finding loopholes and taking advantage of them. I have never even heard the most conservative Coder say that they would need to query the MD in a patient with clinical evidence of sepsis who had negative blood cultures.

This guideline should be brought to the attention of the Coordination and Maintenance Committee for revision.

Just curious, did your patient truly meet sepsis criteria and this was the only way they could find to deny?

Jeff