Sepsis Syndrome

sharon.colesharon.cole
edited May 2016 in CDI Talk Archive
I am looking at a chart that says: “Sepsis syndrome w/DIC”. I found the following coding clinic and it makes it sound as though I don’t need to clarify Sepsis Syndrome. Am I interpreting that correctly? Thanks for your input!!


AHA Coding Clinic® for ICD-9-CM, 2Q 2000, Volume 17, Number 2, Pages 3-7
Sepsis syndrome comprises septicemia with evidence of inadequate organ perfusion with at least some degree of one or more of the following: hypoxemia (PaO2< 75 mmHg); elevated lactate (>5 meq/L); oliguria (< 30mL/hr urine); altered mentation (Glasgow coma score); disseminated intra-vascular coagulopathy (DIC); decreased platelets; increased INR; and/or increased fibrin split prod-ucts (FSP).


Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org

Comments

  • ddouthitddouthit
    edited May 2016
    Sharon,

    Unfortunately coding clinic clarified this with latest coding clinic. You will need to query.

    Sepsis syndrome clarification
    Coding Clinic, Second Quarter 2012 Pages: 21-22 Effective with discharges: July 17, 2012



    Question:

    The provided listed "sepsis syndrome" in the final diagnostic statement. How should sepsis syndrome be coded? The only advice we have found on sepsis syndrome was a Coding Clinic reference from Second Quarter 2000 regarding septicemia, septic shock and sepsis syndrome. Is that advice still valid?

    Answer:

    No, the coding advice on sepsis has changed since that Coding Clinic reference was published. The term "sepsis syndrome" is poorly defined. Query the physician to determine the specific condition(s) the patient has.


    Dorie Douthit, RHIT,CCS
  • sharon.colesharon.cole
    edited May 2016
    Thanks Dorie! Not sure why I found the 2000 CC and not the 2012 one when I looked it up.

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    Sharon.cole@phn-waco.org
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Thanks for sharing, Dorie. This is a tough one for me to accept, but accept I shall.


    Ugh – I 100% understand we are compelled to follow the ‘law’ of Coding Clinic, but this one seems a bit Draconian IMO. When we have a pt with DIC and other supporting clinical evidence supporting Sepsis, this seems not logical. However – ‘it is what it is’. Just my frustration on this topic given I am using Quantim and I don’t have access yet to 2nd Qtr of 2012, so I had not seen this issue of Coding Clinic.


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

    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org
  • sharon.colesharon.cole
    edited May 2016
    Thank you Paul!! Now I don’t feel like such an idiot for not being able to locate that CC – (we use Quantim too).

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    Sharon.cole@phn-waco.org
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Sharon: I have been using Quantim for about 15 years - for whateve reason, it takes them 'about 6 months' to download the Paper Version of Coding Clinic to the Reference Section of Quantim. For instance, you can search and read Coding Clinic in your tools section by date published - 2nd Qtr 2012 is absent.

    3M seems to make this vital reference available on a more timely basis - I am not sure why this is so.

    Paul
  • terrierprideterrierpride
    Hello all,

    Has anyone else implemented the advice about sepsis syndrome in the most recent coding clinic update? Our facility has been coding sepsis syndrome as sepsis forever and this looks like one more battle to fight in the ongoing sepsis war. I'd love to hear any feedback from other CDI Professionals!

    Kevin O'Neil, RHIT
    Herrin Hospital
    Herrin, IL
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    We just put this out....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • Unknown
    edited May 2016
    Great! We always query for that phrase. Thanks for sharing

    Jamie Dugan RN
    Clinical Documentation Improvement Specialist
    Baptist Health System
    office:904-202-4345
    cellular: 904-237-7253
    Business Email-jamie.dugan@bmcjax.com
    cdis.icd10@bmcjax.com
  • Unknown
    edited May 2016
    We too are having to correct for 'sepsis syndrome' which has been used and accepted for some time. We are writing queries stating there is a recent publication by AHA Coding Clinic that states it is a non-specific term. That way physicians know we are not dreaming up a way to ask another question:)

    Linda Haynes, RHIT, CCDS | Clinical Documentation Manager | Legacy Health | Portland, Oregon |
    P: 503-415-5609 | lhaynes@lhs.org
  • tkreilingtkreiling
    edited May 2016
    Would you mind sharing your query or how you phrase your query. Thank you.

    Tara
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    How is everyone querying for this. I hate to use the generic sepsis query we generally use because I feel like it makes us look like we are crazy! We have documentation of "sepsis syndrome" and are querying for "sepsis". Even with our attempt at education, I think the providers will be confused and perhaps think we are looking for something else.
    I'd love to use something similar to our "urosepsis" query which basically states that urosepsis is documented and asks them to clarify whether when they use this term they are referring to sepsis 2/2 UTI or UTI (other, unable to determine). However, in this case, there isn't really an alternative, just the suggestion to query when we see it.

    Thanks!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • tkreilingtkreiling
    Would anyone mind sharing their query that they use when they see this term?

    Thanks,
    Tara
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Jinx!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • Unknown
    edited May 2016
    Yes Tara will send you the wording. Will be a bit but will do it! jamie

    Jamie Dugan RN
    Clinical Documentation Improvement Specialist
    Baptist Health System
    office:904-202-4345
    cellular: 904-237-7253
    Business Email-jamie.dugan@bmcjax.com
    cdis.icd10@bmcjax.com
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I have several. Anything particular you are looking for?

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I don't have anything specific to chest pain or syncope.

    Hope they help!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    Do you have one for Acute Resp Failure?

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603
    Pager: 98-1001
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I do. It is old and kinda complicated. It could use paring down :)


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    No problem. Thank you Katy!!! :)

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603
    Pager: 98-1001
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    You're welcome!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • terrierprideterrierpride
    edited May 2016
    Thanks for the flyer! This is a huge help!

    Kevin
  • kmckaigkmckaig
    edited May 2016
    Katy, your tips are great!!! Thanks for sharing.


    Karen McKaig, BSN, RN, CCM, CPUR, CCDS
    Case Manager
    Clinical Documentation Specialist
    Baxter Regional Medical Center
    Mountain Home, AR 72653
    870-508-1499
    kmckaig@baxterregional.org
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Happy to help!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • jolene.filejolene.file
    GREAT Doc tips!
  • gwojogwojo
    edited May 2016
    Katy, this is wonderful! Thanks for sharing.



    Francisca Wojciechowski, BS, RHIA, RHIT, CCDS

    AHIMA-Approved ICD-10-CM/PCS Trainer
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Thanks!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • annnd2009@gmail.comannnd2009@gmail.com
    edited May 2016
    I have a question on this.

    I may not understand, but per the tip sheet if a doctor suspects a pt has a uti and has a fever and tachycardia 110, that would equal- sirs plus source and codes to Sepsis??? Even if not showing hemodynamic instability???
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    This is the guidance I have received from our physicians and the literature that I am familiar with. However, obviously as for any diagnosis, clinical corroboration is necessary. Plenty of patients present with tachycardia and tachypnea and don't have "SIRS". They may be anxious or have taken a jog, or a million other reasons. It is at the discretion of the provider to determine whether the patient has SIRS or Sepsis (if a infectious source is suspected). The documentation of SIRS or Sepsis is required in order to actually code those diagnoses. The clinical indicators are not enough.

    I have use the attached resource for my own use (it is borrowed from MD Anderson, I found it online)

    http://www.mdanderson.org/education-and-research/resources-for-professionals/clinical-tools-and-resources/practice-algorithms/clin-management-sepsis-management-adult-web-algorithm.pdf



    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • vivian.gannonvivian.gannon
    edited May 2016
    That is wonderful resource material!
    Thank you, Katy!

    Vivian


    Vivian E. Gannon RN,CCM,CCDS
    Clinical Documentation Improvement Coordinator
    Chesapeake Regional Medical Center
    vivian.gannon@chesapeakeregional.com
  • tkreilingtkreiling
    Does any one have a query they have been using for sepsis syndrome they would be willing to share?
    Thanks,
    Tara, RN, CCDS
  • lprescottlprescott
    edited May 2016
    Not sure how this will translate with cut and paste. but begin with your clinical indicators and thenrefer to below:


    Please clarify which, if any, of the following is the most likely etiology of the above symptoms and treatment rendered:
    - SIRS (Systemic inflammatory response syndrome based on 2 or more criteria listed below)
    - Sepsis (SIRS due to an infection)
    - Severe Sepsis (sepsis with organ dysfunction)
    - Septic Shock (severe sepsis with hypotension and organ hypoperfusion)
    - Sepsis/SIRS due to urinary source (Urosepsis)
    - Sepsis/SIRS due to an implanted device (F/C, PICC line, joint prosthesis, etc.)
    - Sepsis/SIRS due to a localized infection (cellulitis, pneumonia, UTI, etc.)
    - UTI (codeable term for documented urosepsis)
    - Localized infection only, without systemic illness (please specify site)
    - Bacteremia (abnormal lab finding only, does not indicate systemic illness)
    - Other
    - Unable to determine

    Criteria for SIRS (Systemic Inflammatory Response Syndrome) criteria from Merck Manual:
    - Fever > 100.4°F or hypothermia < 96.8°F
    - Leukocytosis – WBC > 12,000 or leukopenia, WBC < 4,000, or > 10% bands
    - Tachycardia- > 90 beats/minute
    - Tachypnea- RR > 20 breaths/minute or PaCO2 > 32mmHg

    I teach my doctors to state the diagnosis sepsis and then continue with words "as demonstrated by".... and then write the symptoms using the SIRS criteria. Hope this helps.

    Laurie L. Prescott RN, MSN, CCDS
    lprescott@morehead.org
  • cnolan@swgeneral.comcnolan@swgeneral.com
    edited May 2016
    Attached is a form we use here drafted from 3M's recommendation.
  • mdomineseymdominesey
    edited May 2016
    Attached is the one I created for Sepsis/SIRS based on the clinical criteria and providing all relevant choices including an option for not present or unable to determine. I use this one for all iterations inlcuding "Sepsis Syndrome" as I have a place where I enter the relevant quotes and information from the patient's chart. It is a progress note that is entered into the medical record when the physician signs it. It has been approved by my ICU physicians and my hospitalist group.
  • sharon.colesharon.cole
    edited May 2016
    Someone asked about interview questions. I forgot I had compiled these for the last position we were trying to fill. Hope it helps. Feel free to use them if you choose.

    Sharon Cole, RN, CCDS
    CDI Specialist
    Providence Health Center
    254.751.4256
    Sharon.cole@phn-waco.org
  • [Deleted User][Deleted User]
    edited May 2016
    There was an article on this topic in the latest CDI Journal "Coding Clinic prompts fresh sepsis education"
    http://www.hcpro.com/acdis/details.cfm?topic=WS_ACD_JNL&content_id=288080

    Hope this helps!


    Melissa Varnavas| Senior Managing Editor
    Associate Director|ACDIS
    75 Sylvan Street, Suite A-101
    Danvers, MA 01923
    P 978/406-4711 | www.acdis.org
    Mvarnavas@cdiassociation.com
Sign In or Register to comment.