Q&A: Querying for SIRS when clinical indicators are present

Q: Is systemic inflammatory response syndrome (SIRS) an inherent part of an infection? For example, when a patient comes in with pneumonia, and clinical indicators are present for SIRS but the physician did not specifically write SIRS, should coders or CDI specialists query physicians?

A: SIRS is a response by the body to dead or injured cells. It is inherent in infections and should not be sought after when the condition is an obvious infection. Pneumonia, for example, is an obvious infection.

Certain advice from coding authorities has CDI specialists/coders to lead physicians down the garden path of identifying and documenting SIRS whenever a patient has two of the four criteria described in the Journal of Critical Care Medicine. However, the criteria for SIRS referenced in the article were actually established in 1992 as part of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. The conference concluded that the manifestations of SIRS include, but are not limited to:

• Body temperature less than 36°C or greater than 38°C
• Heart rate greater than 90 beats per minute
• Tachypnea (i.e., high respiratory rate) with greater than 20 breaths per minute and/or an arterial partial pressure of carbon dioxide less than 4.3 kPa (32 mmHg)
• White blood cell count less than 4000 cells/mm3 (4 x 109 cells/L) or greater than 12,000 cells/mm3 (12 x 109 cells/L), and/or or the presence of greater than 10% immature neutrophils (band forms)

But soon CDI specialists/coders started to query physicians about SIRS when only a couple of the aforementioned criteria were present regardless of how sick the patient was and regardless of whether vital sign changes were even related to the identified infectious process.

Overcoding SIRS leads to inappropriate billing, not to mention the potential for RAC recoupments and tremendous penalties if identified by the Office of Inspector General.

When a patient has sepsis (ICD-9-CM code 038.xx), the patient has sepsis.

The 2001criteria for sepsis from the Journal of Critical Care Medicine emphasizes that. It states that the patient has to be truly sick from the infection. If the patient does not have sepsis in the face of an infection, the presence of SIRS is implied.

Virtually all patients with acute appendicitis meet the criteria for SIRS, and it’s only the rarest cases of appendicitis that have sepsis. Most patients with bacterial pneumonia exhibit signs and findings of SIRS, but most receive outpatient treatment and do not have sepsis.

Editor’s Note: This article first appeared on JustCoding.com.