Guest Post: Look for underlying infection, organ failure, when clarifying sepsis-related conditions

October 15, 2013

CDI Blog - Volume 6, Issue 40

by Robert S. Gold, MD

In 2004, the Coordination and Maintenance Committee created a definition of sepsis that became the basis of ICD-9-CM’s Official Guidelines for Coding and Reporting and was used in a number of AHA’s Coding Clinics. That definition included the supposition that Systemic inflammatory response syndrome (SIRS) plus infection equals sepsis. But that was misunderstood by readers and is only valuable for patients who are critically ill.

In August 2012, the Surviving Sepsis Campaign developed more specifics about which pressors to use in septic shock, the limitations of stress steroids, and the mechanics of ventilator use with acute respiratory distress syndrome (ARDS). In addition, the Surviving Sepsis Campaign paid a lot of attention to the pediatric patients with recommendations about the use of sepsis definitions for children, which had not been previously identified appropriately.

Clinical presentations can vary depending on the original site of the infection, but can also be nonspecific. You can have sepsis, and you know that the patient has sepsis, but you may never find the infection of origin. Or you may have systemic inflammatory response without sepsis because it’s due to something else.

Common symptoms of the body’s systemic response to inflammation include:

Fever or hypothermia
Tachycardia
Tachypnea
Elevated or low white blood cell count

These are only symptoms, only lab abnormalities, unless it is determined that their presence is due to the body’s response to an infectious or noninfectious source of inflammation.

Increased efforts by CDI specialists in part led to physicians documenting SIRS even when the workup showed that the patient’s tachycardia was due to atrial fibrillation or rapid ventricular response, and the leukocytosis was due to some steroid injections, and the patient didn’t have the systemic response to an inflammatory process at all.

Physicians don’t always document organ dysfunction well, which can cause problems for coders. In order to code severe sepsis, coders need documentation of organ failure. They also need to know the underlying infection.

Editor’s Note: This article was adapted from “Clinical information, queries help reduce confusion when coding sepsis,” published in JustCoding.com.

Found in Categories:

ACDIS Guidance, Clinical & Coding