"SIRS criteria" vs "SIRS" in provider diagnostic statements

tmcginn@northshore.org

Colleagues,
At your respective organizations, how do you interpret, query for, and/or code the following diagnostic statements:

"3/4 SIRS criteria d/t UTI"
Or,
"3/4 SIRS d/t UTI"

At our organization there are differing opinions on having the word "criteria" in there or not, and having the count of "2/4, or 3/4" in there or not.

Some coders ask that we query providers so that the word "criteria" is not used in the diagnostic statement or that the number of criteria is eliminated - and get down to just "SIRS d/t UTI".

Physicians typically do not understand why they would be asked to remove such descriptions - so I am curious what other organizations do.

Our coders tell me there is not an official guideline on the word "criteria" being in the diagnostic statement or not - and whether this should influence the coding process or not.

Any help from your respective organizations is appreciated.

Tricia McGinn, MBA, BSN, RN
Director, Clinical Documentation Integrity
NorthShore University HealthSystem
4901 Searle Parkway, Suite 330
Skokie, IL 60077
Phone: 847-982-4212
Fax: 847-982-4273
tmcginn@northshore.org

cynthia.a.goewey

Tricia,
Some of our physicians document the patient has SIRS physiology or septic physiology, at times stating meets 3/4, etc. Our coders will not code SIRS or sepsis when it is documented this way and we have to query the provider to have them document if the pt did indeed have SIRS or sepsis.
Cindy

paxneros

Our query has an area for us to indicate which clinical indicators (criteria) are met but this is more to support the thought process behind why we are querying. We are asking for the diagnosis "Sepsis due" to or "SIRS due to". We do not ask the physician to document how many criteria are met.

As a coder, I would first hone in on that term Sepsis or SIR. All the other info. Is extraneous. My second step would be to validate the clinical indicators for myself. I would never take someone elses word for it - especially if my initials are going on the chart.

Wonder if it may be a red flag indicator for RAC? I could see them wondering, Criteria? What criteria? May we see this criteria? But as long as you have facility documentation to support the criteria...

"Sepsis due to" or "SIRS due to" sound more precise and clear than "criteria" in my opinion but if it still achieves the desired documentation...

NBrunson, RHIA, CCDS

kshumpert

I myself do not see a problem when the physician documents criteria for any condition. They already list diagnostic tests and laboratory values many times to support a diagnosis. I have found the additional documentation of criteria helps to prevent RAC denials. I think the more criteria documented demonstrates the increased complexity of the patient. I like to see the actual criteria documented. I would be more concerned that it is documented as SIRS and not Sepsis. Just my thoughts...


Kathy
Kathy Shumpert, RN, CCDS

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Pager 765-454-3465
Fax 765-453-8152

When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela

fishdl@shands.ufl.edu

I agree with Kathy - I don't see a problem when the criteria is documented, and share her concerns regarding the documentation of SIRS but not sepsis.

We recently had a chart which included the following:
"Urinary tract infection/SIRS- Proteus positive on urine cultures. Continue Cefepime. Patient afebrile for last 24 hours . Blood cultures no growth to date. NO leucocytosis. Will continue to watch closely. Had some low blood pressure readings but no signs of sepsis or dehydration."

Since SIRS related to an infectious source codes to sepsis, but the physician explicitly states "no signs of sepsis", how should this be coded?
Thanks.