ED Coding and Reimbursement Alert

You should note that code 995.91 is the same as sepsis, Kennedy says. For 995.92, however, you must see the phrase "severe sepsis" (which is generally defined as requiring organ system failure) to report it -- even if you know the patient's condition by looking at the chart -- so make sure your physicians know they need to write those specific words.

"You need the symptoms of SIRS to use the 995 code, and sepsis should only be used if it's specifically stated as sepsis," says Kimberly Engel, coder at Infinity Healthcare SC in Mequon, Wis. When reporting codes that describe SIRS with organ failure (995.92 and 995.94), be sure to report the code for the dysfunction and underlying condition in addition to the SIRS code.

For example, suppose the documentation states that the patient has sepsis from a viral infection and has organ failure because of it. In this case, you would first report the underlying condition, the infection itself, with 079.99 (Unspecified viral infection). Then you would report the sepsis with 995.92, as long as the doctor has stated "severe sepsis."

Finally, you would code for the symptoms of the organ dysfunction. For instance, if the patient had respiratory failure and renal failure, you may report 518.81 (Acute respiratory failure), and 584.9 (Acute renal failure, unspecified), depending on the nature of the dysfunction.

Understand SIRS to Understand Sepsis

Sepsis, by definition, is the systemic inflammatory response to infection manifested by certain SIRS conditions. Essentially, if the patient has an infection and develops SIRS, the intersection of these conditions is sepsis.

SIRS may result from a number of conditions, including pancreatitis, burns, trauma, or infection, among others -- so you should keep in mind that "SIRS doesn't necessarily mean the patient has an infection," Kennedy says. "I talk to coders all the time who see the elevated white count, the elevated temperature," which are components of SIRS, and they conclude, " 'Oh, there must be an infection.' But other things can cause this," such as burns, stress reactions, and trauma. In order to develop sepsis, though, the SIRS must be due to infection.

Look for: One advanced condition for a patient with sepsis is multiorgan dysfunction, a condition in which the patient's organs are temporarily stunned. The patient may then have ailments such as low platelet count, confusion or psychosis, jaundice, or renal dysfunction. And the ICD-9 list also includes such conditions as fever (780.6), tachycardia (785.0), tachypnea (786.06), leukocytosis (288.8), and leukopenia (714.1).

Keep your eyes peeled for these common phrases physicians use to define multiorgan dysfunction: metabolic acidosis, septic encephalopathy, renal failure, and liver failure.

Knowing the giveaway multiorgan dysfunction terms will help you decide when you need to query the physician to properly report his services, Kennedy adds.

Locate Sepsis on the Disease Continuum

In order to filter through physician documentation on a sepsis patient, you'll need to know the possible degrees of inflammatory response. For example, a patient has an infection that results in SIRS, which means he has sepsis, during which he may have hypotension and other symptoms.

The sepsis goes uncontrolled and turns into severe sepsis, and the patient's organs fail. If the severe sepsis advances, the patient has septic shock, a condition in which his low blood pressure is unresponsive to fluid resuscitation and his organs don't respond to treatment.

Don't Be Fooled by Adjectives

Instead of describing a patient's condition with the term SIRS, the physician may say the patient has a certain type of sepsis by associating the condition with an organism, an anatomic area, or a clinical circumstance. For example, you may need to code conditions such as "pneumococcal sepsis," "urinary sepsis," or "puerperal sepsis."

For sepsis described by an organism, such as Gram-negative or pneumococcal, you should report the SIRS code (995.91) as well as the underlying cause of infection, Kennedy says. Tip: Report the underlying condition first, Kennedy says.

If the descriptor is an anatomic area or clinical circumstance, you won't use a SIRS code at all, but a code specific to the infection of that location or circumstance. For urinary sepsis, for instance, you'd report 599.0 (Other disorders of urethra and urinary tract; urinary tract infection, site not specified) and add the septicemia code 038.9. "Code 995.9x is for SIRS, not urosepsis and not sepsis," Engel says.

"This is a good example of how there can be a disconnect between coding and clinical medicine," says Michael A. Granovsky, MD, CPC, FACEP, chief financial officer at Greater Washington Emergency Physicians in suburban Maryland. With the new codes for sepsis in 2004, Granovsky says, you have an important opportunity to feed charts back to physicians for educational purposes. You might even want to hold a mini-ICD9 in-service regarding the new codes, because these coding rules have evolved quite a bit this year, he says.

"Physicians documenting a diagnosis of 'urosepsis' may be describing a patient with a urinary tract infection (UTI), fever and dehydration, a patient with SIRS secondary to a UTI, or full-blown septic shock," Granovsky says, so their documentation needs to be even more specific than it has in the past.

Don't Confuse Sepsis With Septicemia

Septicemia is no longer equivalent to sepsis as of the 2003-04 ICD-9 changes, Kennedy says. "If the physician documents sepsis, code sepsis (995.91 or 995.92) plus 038.9 (Septicemia). If the physician documents septicemia, you should report 038.x only, omitting 995.91 or 995.92. For you to report a sepsis code, the physician must also document "sepsis" or "severe sepsis," Kennedy says. Keep in mind that neither "sepsis" nor "septicemia" requires documentation of a positive blood culture for you to report their respective codes.