Q&A: Sepsis vs. SIRS

February 4, 2010

Q: A patient with a urinary tract infection appeared septic, and she also fit the criteria for sepsis. The physician documented the patient had SIRS but not sepsis. From a coding standpoint, SIRS is sepsis. So I’m confused about the physician’s thought process. Would I incur any risk if I reported ICD-9 code 038.9 as the principal diagnosis and then the SIRS as a secondary diagnosis?

A: SIRS is not synonymous with sepsis. SIRS is sepsis only when the physician documents it as being due to an underlying infection. Report ICD-9 code 995.90 for SIRS alone. Follows the usual coding conventions for sepsis when reporting SIRS due to an infection.

When a physician only documents SIRS in the medical record, coders should automatically query for its underlying cause. Coders should ask the physician the underlying cause of SIRS to determine whether there is SIRS due to infection (i.e., sepsis) or whether there is SIRS that is due to non-infection. The fact that the physician only wrote SIRS is not specific enough to assign the appropriate code, and it could make the hospital vulnerable to a denial.

Note that just because SIRS and a urinary tract infection coexist does not mean that they’re linked. Look in the ICD-9-CM alphabetic index under SIRS, which states the following:

SIRS (systemic inflammatory response syndrome) 995.90 due to

–        infectious processes 995.91

–        with organ dysfunction 995.92

–        non-infectious process 995.93

–        with acute organ dysfunction 995.94

There is no an automatic linkage between SIRS and infections like we have with diabetes with osteomyelitis or gangrene. The physician must explicitly state what condition causes the SIRS.

Query the physician to obtain the link. Also ask whether it was present on admission (POA). When it’s not crystal clear that sepsis or SIRS was POA, coders are required to query. Failure to do so is a violation of the ICD-9 guidelines.

When the physician does not document that the patient was systemically ill, he or she is losing one of the major clinical indicators that would support him or her during a retrospective review.

Editor’s note: James S. Kennedy, MD, CCS, FTI Healthcare in Atlanta answered this questions during the “Sepsis Documentation and Coding: Clinical Indications, ICD-9 Guidelines, and Queries for Clarity” audio conference. E-mail him at james.kennedy@ftihealthcare.com.

Get additional information in the live February 19, 2010 audio conference production Sepsis Coding and Documentation: Case Studies to Prevent Common Mistakes.

Found in Categories:

Ask ACDIS