Q&A: Sepsis physiology versus a sepsis diagnosis

Q: We recently had a patient who became hypoxic during their hospitalization, with oxygen saturation requirement and hypotension and tachycardia. The chest x-ray showed new right greater than left (R>L) basilar opacities. The physician documented concern for infection and started the patient on vacomyocin/cefepime and fluid resuscitated.

Given the location of the opacity and how quickly the patient’s symptoms started/resolved, the physician documented aspiration pneumonitis in the setting of altered mental status with concurrent hypovolemia driving sepsis physiology rather than true pneumosepsis (no fever, leukocytosis, or bacteremia), although the patient meets the criteria for hospital acquired pneumonia (no opacity on the initial chest x-ray, then new opacity roughly 48 hours later with respiratory symptoms).

Based on these findings, can sepsis be coded? What is the difference between sepsis physiology and true pneumosepsis?

A: To answer this hypothetical, I would need a bit more information. What was the evidence that the patient was aspirating? You wouldn’t just jump directly to aspiration pneumonia without some evidence that the mechanism of aspiration was present/had actually occurred.

Remember sepsis is a dysregulated host response to an infection leading to organ dysfunction and sometimes shock and even death.

To the second part of the question, pneumonia can give a false negative initial chest x-ray finding when patients are initially dehydrated and then rehydrated. The pneumonia was present on admission but was not displayed on the x-ray due to the dehydration and upon rehydration became visible. The dehydration could also account for the initial hypotension if it simply resolved due to rehydration would not be indicative of septic shock. Additionally, the transient labile hypotension is not a valid indicator of the quick sequential organ failure assessment (qSOFA) for sepsis if it simply resolved with some IV fluid and never returned/didn’t correlate with resolution of sepsis symptoms.

Sepsis is not a true independent diagnosis or a single indicator, but rather an amalgamation of the totality of many different elements in the patient’s record which could lead a physician to suspect sepsis and because of this, the diagnosis has a high degree of subjectivity. There are many indicators which by themselves could mean sepsis, but they could also mean four or five different diagnosis. We call this “lack of specificity,” meaning the findings might nearly always be present in sepsis cases (reliability), but they are also present with many different diagnoses (specificity).

Your question touches on one of the biggest issues with sepsis. It is highly complex, highly variable, and highly dynamic as a diagnosis. This is why Coding Clinic specifically mentions sepsis in relation to the Official Guidelines for Coding and Reporting, stating that the coding (or the choice not to code) of a diagnosis such as sepsis is not based on indicators but rather the physician’s diagnostic statement. It is beyond the skills of a CDI specialist or a coder to make that final determination.

Finally, I would also not be so quick to rule out sepsis based on a lack of fever, leukocytosis, or bacteremia. You need more information first. Seventy percent of all true sepsis cases are culture negative (no bacteremia detectable) so that by itself is not an exclusion criteria. If the patient is immunocompromised in anyway, such as with cancer or HIV disease patients or patients who are on immunosuppression, have a congenital immune-compromise, or are extremely young, or in extreme advanced years, they may very well be septic without displaying a normal systemic inflammatory response syndrome (SIRS) response of fever and leukocytosis. Again, that would have to be the physician’s assessment, but you need to look at much more than just the presence or absence of SIRS to get to the truth. Likewise, many patients who actually have SIRS aren’t septic.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for HCPro in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, click here. Want to know about sepsis conundrums? Join us for a 90-minute webinar on July 18!