Translate Sepsis Clinical Conflict
By Jennifer Avery, CPC, CPC-H, CPC-I, CCS
Septicemia, sepsis, and systemic inflammatory response syndrome (SIRS) are all terms physicians use and coders are used to seeing in sepsis documentation. The meaning of these terms, however, is often open to interpretation. One physician’s septicemia is another physician’s sepsis. The interchangeable use of these terms by physicians can create a gray area in documentation for coders. Suddenly you are faced with the task of translating a chart to code the diagnosis. You can, however, clarify sepsis confusion simply by knowing what to look for in the documentation.
The best approach is to provide physicians with coding guideline education on what is necessary in clinical documentation, on query forms, and in internal clinical or coding reviews. Only then can a coder clear up confusion about whether sepsis is an appropriate final diagnosis.
Septicemia and Sepsis Confusion
According to ICD-9-CM, septicemia generally refers to a systemic disease associated with the presence of pathological organisms or toxins in the blood, which can include bacteria, viruses, fungi, or other organisms; systemic inflammatory response syndrome, or SIRS, generally refers to the systemic response to infection, trauma/burns, or other insult (such as cancer) with symptoms including fever, tachycardia, tachypnea, and leukocytosis; and sepsis refers to SIRS caused by an infection. Part of clearing up sepsis confusion is understanding the different clinical terms and what they mean.
An infected patient who is truly septic or toxic will present with three or more of the following conditions:
- Temperature > 101° F or < 96.8° F
- Pulse > 90/min
- Respirations > 20/min
- White blood cells (WBC) > 12,000 or < 4,000 or > 10 percent bands formed
- Acute organ dysfunction
Using these criteria as a guide, you should be able to identify a septic patient and, if necessary, question these indicators’ clinical significance to the physician with confidence to ensure documentation reflects the patient’s true diagnosis.
The ICD-9-CM index prompts the use of code 038.x Septicemia to code septicemia conditions; however, this code represents “systemic infection or toxemia,” whereas sepsis is a systemic response to systemic infection or toxemia. An instructional note at category 038.x indicates an additional code from category 995.91-995.92 is necessary to identify systemic SIRS. Based on the official coding guidelines, 995.9x Systemic inflammatory response syndrome (SIRS) identifies the septicemia’s progression into sepsis.
Used alone, the term urosepsis refers to a localized infection found in the urinary system (ie, a urinary tract infection [UTI]). The Official ICD-9-CM Guidelines for Coding and Reporting is very specific for urosepsis:
“The term urosepsis is a nonspecific term. If that is the only term documented then only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism if known.”
Many physicians believe urosepsis refers to sepsis and give coders the underlying cause as a UTI. To clear up any confusion, ask the physician whether the patient simply has a UTI or if the patient has sepsis with UTI as the cause.
Line sepsis has also become a nightmare term for coders. Line sepsis used alone refers to an infection due to vascular catheter presence. You should report line sepsis with 996.62 Infection and inflammatory reaction due to vascular device, implant and graft. When a physician documents sepsis due to a vascular catheter, correct coding also includes the code for sepsis (eg, 038.xx and 995.91 Systemic inflammatory response syndrome (SIRS); sepsis or 995.92 Systemic inflammatory response syndrome (SIRS); severe sepsis, depending on the documentation). (Guidance from the American Hospital Association Coding Clinic Fourth Quarter 2007; Second Quarter 2004 provides additional information.)
The presence of “line sepsis” in documentation should prompt the coder to seek physician clarification.
Coders also need to identify and understand when to apply an additional code for SIRS. There are two classifications for SIRS: infectious and noninfectious. The Official ICD-9-CM Guidelines for Coding and Reporting prompts coders to use the additional code 995.9x when documentation identifies sepsis or severe sepsis. The guidelines indicate at least two codes are necessary: Codes 038.x (systemic infection) and either 995.91 (sepsis) or 995.92 (severe sepsis). Additional codes may be necessary to identify associated localized infections or organ dysfunction. In a perfect world, the documentation would be this clear.
It is possible to have a patient with SIRS, but not sepsis or severe sepsis. Remember, there are two types of SIRS (ie, infectious and noninfectious). Pancreatitis, burns, trauma, or malignancy can all cause SIRS. In such cases, it is inappropriate to assign a code from category 038.x. Coding guidelines are not as clear as coders might like because the existing guidelines aren’t edited; rather, additional information is tacked on. The good news is, “Physicians rarely use the term SIRS unless educated about it in clinical documentation type arenas. We may see it in trauma or burn units; however, rarely do we see it elsewhere,” according to James S. Kennedy, MD, CCS, FTI Healthcare director and a nationally known expert on hospital coding.
Per the Official ICD-9-CM Guidelines for Coding and Reporting, SIRS can develop due to certain noninfectious diseases processes (eg, trauma, malignant neoplasm, or pancreatitis). When a physician documents SIRS with a noninfectious condition and no other infection, you should report the code for the underlying condition (eg, an injury), followed by code 995.93 Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction or 995.94 Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction. When the physician documents any associated acute organ dysfunction, an additional code is necessary. When a physician documents acute organ dysfunction without a link to SIRS, coders should query the physician.
These terms are difficult; and coders and physicians may understand them differently. Coders should learn how to defend themselves during an audit. Remember: It isn’t a coder’s responsibility to question a physician’s clinical judgment, but it’s a coder’s responsibility to clarify gray or nebulous documentation.
The best approach is to provide physicians with coding guideline education on what is necessary in clinical documentation, on query forms, and in internal clinical or coding reviews. Only then, can a coder clear-up confusion about whether sepsis is an appropriate final diagnosis. In the meantime, coders can feel more secure in their choices by continually increasing their clinical knowledge. Certainly, coders don’t need to become clinicians, but they should consider taking simpler steps, such as keeping a file of notes for clinical indicators, and working closely with physicians to understand the limitations based on coding guidelines. It’s also good idea to use a clinical documentation specialist program or perform concurrent coding if you are not already doing so.
If the physician writes “bacteremia” somewhere in the medical record, assign 790.7 Bacteremia. Bacteremia refers to a positive blood culture reflecting bacteria in the blood. A physician may use this word and the coder may believe the physician is referring to the bacteria causing sepsis. This is not correct according to coding guidelines. Bacteremia is not sepsis and conversely, coders shouldn’t assign 790.7 to describe sepsis. According to ICD-9-CM, bacteremia is categorized as “symptoms, signs, and ill-defined conditions.” Coders should query the physician to determine whether the documented bacteremia is linked to a condition, represents a systemic disease, or is simply indicative of a lab finding.
Toxemia is a term frequently used to indicate toxins present in the bloodstream. Toxemia is often present in patients sustaining trauma, burns, and conditions such as pancreatitis. Toxemia can also be present in obstetrics patients. Report unspecified toxemia with code 799.89 Other ill-defined conditions. When the term “toxemia” is in the documentation, the coder should ask the physician for additional information: Is the toxemia a clinical finding, or is it associated with another, more specific condition?
Sepsis typically refers to a localized infection, but based on clinical data (eg, SIRS criteria) may be systemic. What should a coder do when a physician uses the term sepsis following or in combination with other terms (eg, line sepsis or urosepsis)? Based on the record’s clinical data, the coder should query the physician to clarify whether he or she is referring to a localized infection or one that has become systemic.
Jennifer Avery, CPC, CPC-H, CPC-I, CCS, a Davenport University graduate in Health Claims Management and Medical Assisting and an approved Professional Medical Coding Curriculum (PMCC) instructor, is the lead instructor for the Certified Coder Boot Camp®– Original Version and an instructor for the inpatient version. Prior to joining HCPro, Inc., Jennifer worked for Health Partners Investments, LLC and for Coding by the Numbers. She also served as president of the Oklahoma City chapter.