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Coding Guidelines:

LEARN THE SHOCKING TRUTH ABOUT THIS QUIET THREAT TO YOUR SEPSIS CLAIMS

Published on Tue May 24, 2005 Print Friendly and PDF PDF

Don't hesitate to ask - even docs may get it wrong.

If you think sepsis is the same as septicemia, think again - this misunderstanding could lead to major coding errors.

"Clinicians tend to use the terms 'septic shock,' 'severe sepsis,' 'sepsis' and 'septicemia' interchangeably, but they are really different clinical pictures and outcomes," says Prinny Rose Abraham, formerly with HIQM Consulting in Minneapolis.
 
If you don't know the difference, the Centers for Medicare & Medicaid Services clarifies the correct coding of these infectious conditions in its 2005 update to the ICD-9 Coding Guidelines. But to understand the guidelines, you must first understand the terminology: 

  • Bacteremia is presence of bacteria in the blood and it can be asymptomatic, says registered nurse Paula Hoegemeyer, project coordinator with MPRO, Michi-gan's health care quality improvement organization. The condition may occur after a surgical procedure, labor or even teeth cleaning, and according to the American Hopital Association's Coding Clinic 2000, it "progresses to septicemia only when there is a more severe infectious process or an impaired immune system."
     
  • Septicemia, while similar to bacteremia, implies greater severity. Coding Clinic for fourth quarter 2003 defines septicemia as "pathological organisms (viruses, bacteria, fungus, or other organisms) OR their toxins in the blood." Septicemia may simply involve a positive blood culture and a fever, but "if allowed to progress, may cause overwhelming infection and death," Hoegemeyer adds.

    Tip: Question the physician if septicemia is documented and two or more manifestations of SIRS are present. The patient may actually have sepsis.
     
  • SIRS is an acronym for "systemic inflammatory response syndrome." SIRS may occur in response to multiple causes, only one of which is infection. When SIRS is due to infection, it's called sepsis.Symptoms of SIRS include increased or decreased body temperature, rapid heartbeat, high or low white blood count, and increased respiration.
     
  • Sepsis is a pathological state, usually febrile, resulting in the presence of micro-organisms in the bloodstream, Hoegemeyer says. These micro-organisms can start out from something as simple as cellulitis that, if untreated, may develop into sepsis. Sepsis occurs when septicemia advances to include two or more manifestations of SIRS, without organ dysfunction.
     
    Heads up: Contact the physician if sepsis is documented but the patient doesn't have two or more manifestations of SIRS. Clarify if the patient really has sepsis.
     
  • Severe sepsis is when there are two or more manifestations of SIRS with organ dysfunction.
     
  • Septic shock is severe sepsis in which the cardiovascular system begins to fail, blood pressure drops and vital organs are deprived of an adequate blood supply. Because septic shock cannot occur in the absence of severe sepsis, you must sequence a code from subcategory 995.9 (Systemic inflammatory response syndrome) before the code for septic shock, CMS says.
     
  • Urosepsis is "septic poisoning due to retention and absorption of urinary products in the tissues," Hoegemeyer says.

    Tip: When the physician says urosepsis, he may just mean a urinary tract infection, experts say. But if the patient has a UTI plus symptoms of a systemic response to the infection, the patient may have sepsis, so you should query the physician. 

    Editor's Note: To see the updated guidelines, go to     www.cdc.gov/nchs/data/icd9/icdguide.pdf.

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