Comparing sepsis indicators
The existing clinical indicators we have used for the past 20 years include identifying the presence of two or more of the following four indicators:
- Temperature >38°C or <36°C
- Heart rate >90/min
- Respiratory rate >20/min or Paco2 <32 mm Hg (4.3 kPa)
- White blood cell count >12 000/mm3 or <4000/mm3 or >10% immature bands
- The concept of non-homeostatic host response to infection is stressed while the SIRS criteria have been removed.
- The inflammatory response accompanying infection (pyrexia, neutrophilia, etc.) often represents an appropriate host response to any infection, and may not necessarily be life-threatening.
Three hurdles for clinical coding
Sepsis coding guidelines have been vetted and well-defined over the years. Each healthcare system has established guidelines based on the long-standing definitions, Official Coding Guidelines, and internal medical staff approvals. The new indicators released by JAMA do not match current sepsis coding guidelines: herein lies the issue for coding teams.
Once the new Sepsis 3 indicators are reviewed and approved by each organization’s medical staff, it is the responsibility of HIM and CDI leadership to analyze coding guidelines in terms of the new criteria. There are three primary categories to be aware of with this change:
- Line up coding guidelines to match with the new definition. This is an arduous process that must begin with national updates to established coding guidelines. Each organization can also take the lead internally by reviewing JAMA’s indicators and making an internal decision to update their internal coding guidelines accordingly. Working in conjunction with their medical staff, all CDI, coding teams, and medical staff must be on the same page with new definitions and when the shift will occur.
- Educate coders on the new definition, updated coding guidelines and how coding protocols will change. A structured, intentional education program makes sense to accomplish this goal (suggestions are below).
- Understand the denial impact of timing differences between providers and payers. In all likelihood, payers will start using the new guidelines before we, as coders, have started updating the guidelines. So at the health system level, there must be clear leadership and a defined protocol to realign the sepsis coding guidelines.
Updating your sepsis clinical coding guidelines
In order to get ahead of a solution, physicians, infectious disease specialists, HIM, revenue cycle, CDI, compliance, and coding should ALL be having conversations about these changes and the three impacts mentioned above.
At a recent ACDIS conference “Special Panel Session: New Sepsis Definition”, two physician panel sessions were held to review the new criteria and explore best practices for adoption and implementation. The findings presented at this conference, held in Atlanta in May 2016, delved into some of the coding implications arising from this new definition. Five key points of concern were reiterated during the presentation:
- Sepsis 3 states that “the term severe sepsis was redundant” indicating that sepsis without organ dysfunction does not exist.
- The Sepsis 3 definitions are inconsistent with the ICD-10-CM Official Guidelines for Coding and Reporting (OCG), which distinguishes between sepsis without organ dysfunction and sepsis with organ dysfunction.
- Sepsis 3 makes erroneous recommendations for the “primary” codes to be used pursuant to the new definitions.
- The OCG and ICD-10-CM do not require organ dysfunction be specified as “due to” sepsis for assignment of R65.20 (severe sepsis), but having this documentation makes the connection indisputable.
Click here to view the full slide deck from the panel.
Begin with awareness
The best approach to address coding impacts for sepsis head-on is through awareness and education.
- Begin by awareness through bulletins and written materials.
- Build knowledge through online education portals, lunch-and-learns, and internal webinars.
- Practice the new skill set by using coding training systems and tools.