sepsis and resp failure

katysuegood@gmail.com · February 2016

Hi all,
We have some new (to us) coders and I am working a mortality case right now where we have Acute resp failure and sepsis and the coder has ARF as Pdx. She states that this is fine (in this case) because it was most extensively treated. Patient was on the vent.
This was a short admission, one day. The patient was elderly and moved to comfort care quickly. We never identified the source of sepsis.

I am confused here. I have always been under the impression that sepsis must be Pdx in these cases. Otherwise, we'd always sequence the ARF as Pdx considering it is the higher weight and often no surgical procedure is done for the sepsis or underlying infection.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

evanspx@sutterhealth.org · February 2016

Sepsis is the PDX, in my opinion. I am assuming the ARF is stated as 2/2 the Sepsis? Even if not, it would be difficult to rationalize a an acute failure of only one body system (ARF) over the code used for a systemic infection.

One really has, IMO, very limited options when sequencing Sepsis and the ARF in this particular situation. Again, this is my opinion.

Guidance issued in Coding Clinic 2003, 4th Quarter pertaining to the Chapter-Specific Guidelines for Sepsis/SIRS does not allow acute respiratory failure to be sequenced before Sepsis/SIRS if both are present at the time of admission.

I do not believe a sequencing option exists for a patient admitted with a localized infection that has progressed to septic shock, sepsis or SIRS, regardless of the source of the sepsis, be it a UTI, Decubitus Ulcer, pneumonia, or any other localized infection. It is this author's interpretation of current advice published in Coding Clinic, that when a patient is admitted with sepsis, pneumonia, and respiratory failure, sepsis is the principal diagnosis, regardless of the cause of the respiratory failure, be it sepsis or pneumonia, or of some other or of unknown etiology. Sequencing options sometimes exist when the record documents a situation in which "two or more diagnoses equally meet the criteria for principal diagnosis selection as determined by the circumstances of the admission and the diagnostic workup and the therapy provided".

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org

evanspx@sutterhealth.org · February 2016

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kerryseekircher · February 2016

Agree with you and Paul.
All guidance I have seen points to Sepsis as the PDX.
See also Coding Clinic, Second Quarter 2005-septic shock, resp failure and h influenza pneumonia in which case the coder is directed to sequence the sepsis first.

Kerry

Kerry Seekircher, RN, BS, CCDS, CDIP

katysuegood@gmail.com · February 2016

Thanks Paul!

Would you maintain this is the ARF is not specifically connected to the sepsis?

Just bolstering my argument ;-)

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.94

kerryseekircher · February 2016

Well that takes care of that question Paul: )

Kerry Seekircher, RN, BS, CCDS, CDIP

evanspx@sutterhealth.org · February 2016

Yes, I would...in that case, I'd argue that a Sepsis, being a 'systemic' illness, is of greater acuity than the disease that is limited 'only' to one organ, in this case, the acute respiratory failure.

I am not saying that Sepsis, when POA, is 'always' the PDX for all cases, as we have had instances whereby some very unfortunate individuals were admitted with sepsis and the staff also very clearly stated the pt had a concurrent acute stroke and/or AMI, with the AMI causing Cardiogenic shock and subsequent ATN, and the stroke causing acute respiratory failure (brain stem infarct) So, I believe (again, my opinion) it is possible to conceive very limited cases whereby Sepsis is present at admit, but not 'always the PDX. In such rare cases, Sepsis may not always be the PDX.

However, if a pt has, as one example Sepsis, PNA and Acute Respiratory Failure, I can't see how we can 'parse out' the acute respiratory failure as the PDX over the systemic illness....hope this makes some sense? We have disease of 'only' the lungs and Sepsis...how does the Sepsis not trump by definition of Principal Diagnosis?

We all know my background, (I stand by the coding profession) but I think the coder is on shaky ground with the reasoning on this particular issue. Your coder wishes to apply the principal below, but I don't concur.

Two or more diagnoses that equally meet the definition for principal diagnosis In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org

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katysuegood@gmail.com · February 2016

Thanks Paul and Kerry!!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, February 09, 2016 4:51 PM
To: Kathryn Good
Subject: RE:[cdi_talk] sepsis and resp failure

Yes, I would...in that case, I'd argue that a Sepsis, being a 'systemic' illness, is of greater acuity than the disease that is limited 'only' to one organ, in this case, the acute respiratory failure.

I am not saying that Sepsis, when POA, is 'always' the PDX for all cases, as we have had instances whereby some very unfortunate individuals were admitted with sepsis and the staff also very clearly stated the pt had a concurrent acute stroke and/or AMI, with the AMI causing Cardiogenic shock and subsequent ATN, and the stroke causing acute respiratory failure (brain stem infarct) So, I believe (again, my opinion) it is possible to conceive very limited cases whereby Sepsis is present at admit, but not 'always the PDX. In such rare cases, Sepsis may not always be the PDX.

However, if a pt has, as one example Sepsis, PNA and Acute Respiratory Failure, I can't see how we can 'parse out' the acute respiratory failure as the PDX over the systemic illness....hope this makes some sense? We have disease of 'only' the lungs and Sepsis...how does the Sepsis not trump by definition of Principal Diagnosis?

We all know my background, (I stand by the coding profession) but I think the coder is on shaky ground with the reasoning on this particular issue. Your coder wishes to apply the principal below, but I don't concur.

Two or more diagnoses that equally meet the definition for principal diagnosis In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org

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evanspx@sutterhealth.org · February 2016

My pleasure.

I'd be interested to know if you convince the coder to change the sequencing?

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org

[cid:image001.jpg@01D16352.4EE147F0]

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, February 09, 2016 3:54 PM
To: Evans, Paul
Subject: RE:[cdi_talk] sepsis and resp failure

Thanks Paul and Kerry!!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

ssalinas · February 2016

I was responding in a very similar frame as Paul. Was the patient a chronic vent patient? In that case, if the patient had respiratory failure and was on a vent previous to admit, the sepsis was most likely the reason for the admit. If not, did the physician state a current acute cause other than sepsis for the ARF as Paul outlined below?

I will add that the physician must make the connection between the sepsis and the acute organ dysfunction.

Bottom line - I concur with Paul and Kerry...for what it's worth. It would be difficult to justify ARF over the sepsis.
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Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org

katysuegood@gmail.com · February 2016

For more detail, the patient was a transfer for higher level of care. Originally admitted to the other facility for persistent vomiting 2 days prior to transfer. Very elderly lady. She then went into a-fib with RVR with hypotension not responsive to fluid boluses and a LA >5. She was intubated prior to transfer and came here on the vert. Short LOS. No underlying cause of sepsis identified and no underlying cause of resp failure documented. She was quickly transitioned to comfort care and died immediately after extubation.

The coder did agree to change the sequencing.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

sepsis and resp failure

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