April 9, 2013

Facing the Sepsis Conundrum in the World of ICD-10

By Lisa Roat, RHIT, CCS, CCDS

Understanding exactly what documentation and coding issues clients struggle with the most is one of the benefits I reap from working in a client support role. If I were asked to rank such issues, I would definitely say that bacteremia, SIRS and sepsis are high on the list. Quite honestly, I don’t think there is a question regarding the documenting and coding of bacteremia, SIRS, and/or sepsis in ICD-9-CM that we haven’t been asked.

Considering the facts that ICD-9-CM has been in use for more than 30 years and we still receive numerous questions about these topics, I can only imagine to what degree adding ICD-10-CM to the mix will add to the uncertainty! The intent of this article is to provide a boost to your base of knowledge about clinical documentation and coding as it relates to the sepsis continuum in ICD-10-CM.

Bacteremia

Bacteremia is the presence of bacteria in the blood as evidenced by a positive blood culture. It is often transient and of no consequence; however, sustained bacteremia may lead to widespread infection and sepsis. The ICD-10-CM code for bacteremia, R78.81, can be found in Chapter 18, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings. There are no ICD-10-CM official guidelines for coding and reporting that specifically pertain to bacteremia. However, keep in mind that because bacteremia is classified in the signs and symptom chapter, if a related definitive diagnosis is established by a provider, that definitive diagnosis either would be coded alone or sequenced first, depending on whether the bacteremia was considered an integral part of the disease process. Based on the “excludes 1” note, bacteremia should never be coded with sepsis.

Septicemia

The 2001 International Sepsis Definition Conference opted to omit the term “septicemia” in its official position statement. The updated terminology includes “sepsis” and “systemic inflammatory response syndrome,” and this practice is replicated in ICD-10-CM. There is only a single reference to septicemia in ICD-10-CM, and this can be found classified under the code for sepsis, unspecified organism, A41.9. The ICD-10-CM Official Guidelines for Coding and Reporting have removed all references to septicemia.

Systemic Inflammatory Response Syndrome (SIRS)

The idea behind defining SIRS was to establish a clinical response to a nonspecific condition of either infectious or noninfectious origin. SIRS criteria include:

  • Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)
  • Heart rate of more than 90 beats per minute
  • Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO2) of less than 32mm Hg
  • Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10 percent immature [band] forms)

There are two codes for SIRS of a non-infectious origin in ICD-10-CM, with assignment depending on the presence or absence of associated organ dysfunction: R65.10, systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction and R65.11, systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.

What many of us perhaps would consider one of the most significant classification changes related to sepsis in ICD-10-CM can be found in the SIRS category of codes. There is no longer a code for SIRS occurring due to an infectious process. The only references to SIRS in the ICD-10-CM Official Guidelines for Coding and Reporting are those specifically related to SIRS due to a non-infectious process. There are instructional notes in ICD-10-CM that tell us to code the underlying condition first , meaning the underlying condition should be sequenced before the SIRS code from subcategory 65.1.

Sepsis

Sepsis can be defined as the presence of both an infection and a systemic inflammatory response. The clinical features include two or more of the SIRS criteria occurring as a result of a suspected or documented infection, taking into consideration the entire clinical picture of the patient. In the ICD-10-CM world, in order to accurately reflect the severity of illness and risk of mortality for patients who present with a localized infection, SIRS, and a clinical picture of sepsis, the provider must document sepsis as a diagnosis. A localized infection with clinical documentation of SIRS only can be coded and reported as the localized infection.


Severe Sepsis

When a patient has sepsis with evidence of organ dysfunction, this is known as severe sepsis, and it is classified in ICD-10-CM either with the code R65.20, severe sepsis without septic shock, or R65.21, severe sepsis with septic shock. According to the ICD-10-CM Official Guidelines for Coding and Reporting, an acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the clinical documentation is not clear as to whether acute organ dysfunction is related to the sepsis or another medical condition, querying the provider is recommended.

The coding of severe sepsis requires a minimum of two codes. The first code will identify the underlying systemic infection, followed by a code from subcategory R65.2, severe sepsis. The codes for severe sepsis from subcategory R65.2 can never be assigned as a principal diagnosis. Don’t forget to add the codes for any associated organ dysfunction in order to reflect accurate severity of illness and risk of mortality.

Urosepsis

Any article on clinical documentation and coding related to sepsis would not be complete without mentioning urosepsis. The ICD-10-CM Official Guidelines for Coding and Reporting indicate quite clearly that urosepsis is a nonspecific term that is not synonymous with sepsis. There is no default code for urosepsis in ICD-10-CM, and the provider must be queried for clarification when this term is documented. However, based on the recently published American Health Information Management Association (AHIMA) recommendations regarding diagnosis options for providers, the options available in such a case must be clinically significant and reasonable, as supported by clinical indicators in the health record. A statement of urosepsis should not automatically generate a clarification for sepsis if there are no clinical indicators, risk factors or treatment documented to substantiate a clinical diagnosis of sepsis.

Without doubt, the sepsis conundrum will continue to plague us regardless of whether we are using the ICD-9-CM or ICD-10-CM code set. As professionals within this ever-changing world of healthcare, it is imperative that we continue to work toward enhancing our clinical knowledge levels and critical thinking skills. We need to remind ourselves, perhaps repeatedly, that the true representation of the quality of care provided to a patient, along with acuity of that patient and outcome data, still rests upon the quality of clinical documentation and coding.

Improved data will help improve the quality of healthcare, and isn’t that what it’s really all about?

About the Author

Lisa Roat, RHIT, CCS, CCDS, is the manager of HIM product development and compliance for J.A. Thomas & Associates, a Nuance Company. She is an AHIMA-approved ICD-10 CM/PCS Trainer.

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