Sepsis Sets Off Coding Bias Alarm

Sepsis Sets Off Coding Bias Alarm

Robert S. Gold, MD, wrote a letter (Sepsis Letter) to Medical Classification Administrator Donna Pickett, MPH, RHIA, of National Center for Health Statistics explaining that when the 995.9x code set came out with directions for use, “the sequencing and the reporting in the Official Coding Guidelines for ICD-9-CM and in AHA’s Coding Clinic, the incidence of ‘sepsis’ DRGs reported in the United States rose from 310,000 per year to 750,000 cases per year.” This change cost Medicare anywhere from 1.5 to 3.7 billion dollars in 2005 of additional reimbursements.

Vice President AAPC ICD-10 Development and Training Rhonda Buckholtz, CPC, CPMA, CPC-I, CHPSE CENTC, COBGC, CPEDC, CGSC, brought up the question, “Are healthcare dollars being misspent on diagnostic conditions because of the ICD-9 coding system?” According to Gold, with support of physician experts in the field: Yes! In his letter, he mentions the following areas as the source of sepsis upcoding and pleads for changes to the definitions and guidance, as outlined:

  • 995.91 and 995.92 should be defined as Sepsis and Severe sepsis.
  • Systemic inflammatory response syndrome (SIRS) should be noted as integral to infectious processes and may be utilized as a screening tool by the physicians caring for patients to identify patients at possible risk.
  • SIRS due to noninfectious processes (995.93 Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction and 995.94 Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction) should still be useful, as the criteria are not integral to these conditions.

Gold’s main concern, according to the letter:

The United States is in a crunch monetarily and Medicare and Medicaid as well as all of the other payers for healthcare delivery are under the gun to stay viable. When the rules are wrong, CMS will be hurt as well as all of the rest of us who pay for healthcare. The statistics in the United States are wrong and that is hurting the statistics in the world.

Gold says he has been fighting “this battle” since 2005. “The issue in ICD-9 cost the Medicare program in this country over 7 billion dollars a year since 2006 for people who did not have sepsis — that’s $70 billion thrown away 2004-2014,” he told AAPC.

Will ICD-10 Fix This?

AAPC’s ICD-10 Development and Training were hoping ICD-10’s implementation would change the issues with upcoding. After reviewing the codes, Gold suggested, “We cannot have Coding Clinic or Official Guidelines for ICD-10 even mention SIRS due to infection as being coded to A41.9 Sepsis, unspecified organism. Currently, it’s not there (thank goodness).”

AAPC’s Director of ICD-10 Development and Training Betty Hovey, COC, CPC, CPB, CPMA, CPC-I, CPCD, pointed out, however, “The verbiage under subcategory R65.2- Severe sepsis should be deleted that lists ‘Systemic inflammatory response syndrome due to infectious process with acute organ dysfunction.’”

The best recourse for changing the coding verbiage is getting the word out and explaining the coding and reimbursement inaccuracies. Buckholtz says, “We are working with Dr. Gold, on this one. We can’t help fix it, but we can bring it to light for the industry to see.”

For more information in regards to reporting concerns, read these articles:

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Michelle Dick
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Michelle Dick

Executive Editor at AAPC
Michelle A. Dick has been executive editor for AAPC for over seven years. Prior to her work at AAPC, she was editor-in-chief at Eli Research and Element K Journals, and disk ad coordinator, web designer/developer, and graphic artist at White Directory Publishers, Inc. Dick has a Bachelor of Science in Graphic Design from the State University of New York - Buffalo State and is a member of the Flower City Professional Coders in Rochester, N.Y.
Michelle Dick
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About Has 134 Posts

Michelle A. Dick has been executive editor for AAPC for over seven years. Prior to her work at AAPC, she was editor-in-chief at Eli Research and Element K Journals, and disk ad coordinator, web designer/developer, and graphic artist at White Directory Publishers, Inc. Dick has a Bachelor of Science in Graphic Design from the State University of New York - Buffalo State and is a member of the Flower City Professional Coders in Rochester, N.Y.

One Response to “Sepsis Sets Off Coding Bias Alarm”

  1. andrew gerety says:

    Metabolic Theory of Septic Shock
    Please do a search for the above

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