Severe Sepsis CMS Criteria vs Coding Guidelines

stegmanj@ellismedicine.orgstegmanj@ellismedicine.org
edited July 2017 in Clinical & Coding

I was looking to get some feedback on how other organizations are addressing the differences between CMS Severe Sepsis criteria and the Coding guidelines for Severe Sepsis. - this is mostly specific to NYS hospitals since our DOH does not allow us to eliminate coded cases from the pool when they do not meet CMS criteria -

Currently CMS guidelines for Severe Sepsis are the following:

Patient meets Sepsis criteria AND has NEW onset of one indicator below:

  • SBP < 90
  • Lactate > 2
  • Resp failure requiring vent or Bipap as treatment
  • Bili > 2
  • Creatinine> 3.0 or urine output < 0.5 mL/kg/hr for 2 hours
  • INR > 1.5 or PTT > 60 sec (not on anticoagulants)

Currently the coding tabular index for 2017 states:

  • code R65.2 Severe Sepsis is an infection with associated organ dysfunction including one of the following: 
  • AKI
  • Acute Resp Failure
  • Critical illness myopathy
  • Critical illness polyneuropathy
  • DIC
  • Metabolic Encephalopathy (Septic)
  • Hepatic Failure
(the definition of the word "with" has changed and now coders are allowed to link the conditions without a provider linking them?)

Our coders are automatically linking Sepsis with ANY acute organ dysfunction documented in the chart and adding an additional code for Severe Sepsis.  The problem with this is that not all patients with AKI have a Cr greater than 2, not all patients with Acute resp failure rely on a vent or Bi-pap, ect.  So the patient technically does not meet CMS requirements for Severe sepsis and the cases are being coded as such without a direct link between the organ dysfunction and the sepsis from the MD.  This of course has impacts on quality metrics concerning Severe Sepsis bundles and outcomes. 

We were thinking of adding the CMS criteria above to our hospital specific clinical indicators policy. The coders are unsure if we can add this to the policy or if they need to be held to the wording in the tabular index.  I am just wondering if other hospitals have come across this issue and what have you done to address it.  Any advice is appreciated!!!

Thanks

Jamie Stegmann RN

Lead CDI Specialist

Ellis Medicine

Schenectady NY





Comments

  • stegmanj@ellismedicine.orgstegmanj@ellismedicine.org

    ETA: 

    This is the coding rule regaurding the word "with"

    "With"

    The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.

    The word "with" in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order. ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 Page 13 of 114

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