Q&A: Three query opportunities related to sepsis infections

Q: If we were live with ICD-10 would we query for sepsis infectious versus noninfectious origin in the following scenario?

On admission the physician documents: “Sepsis by definition with heart rate of 120, blood pressure of 70/40, Celsius temperature (T) of 37.5 degrees, on intravenous infusion of Levophed (gtt), with acute kidney injury (AKI), encephalopathy.” Then, on day four of the patient’s stay he documents: “Presumed sepsis with all cultures negative at 72 hours.”

A: First, we need to clarify that sepsis cannot be from a noninfectious origin in the ICD-10-CM code set. “Sepsis” from a noninfectious origin is SIRS. While this is also true within the ICD-9-CM code set, it is less clearly defined there.

The title of the SIRS codes in ICD-10-CM is “SIRS of noninfectious origin” either with or without associated organ failure. This clearly differentiates a systemic response to a noninfectious origin from one resulting from an infection, which would be defined as sepsis.

As such, in ICD-10-CM if the provider documents SIRS due to an infectious condition, you would need to query to see if the provider is really diagnosing SIRS or sepsis.

Here is a sample query that you might pose in this situation:

The diagnosis of specify the local infection appears within the progress notes on _____. The diagnosis of SIRS with infection was documented today. Please clarify if the patient has the following condition:

    Systemic inflammatory response syndrome of a non-infectious origin (specify cause): _________

    Sepsis secondary to pneumonia

    Specify the documented local infection only (a local infection only)

    Unable to determine

    Other _______________________________

Once SIRS is differentiated from sepsis, the CDI specialist would need to determine if the provider established a sepsis diagnosis. If the provider documents “sepsis by definition” and then “presumed sepsis,” we would want to see “presumed” sepsis or just “sepsis” in the discharge summary.

Most coders would consider the way sepsis has been documented in the above scenario as “uncertain.” An uncertain diagnosis can only be coded if it remains uncertain at the time of discharge. I would probably query the provider to clarify if the diagnosis of sepsis has been confirmed or ruled out if it is not addressed in the discharge summary. You might word that query as follows:

“Sepsis by definition with heart rate of 120, blood pressure of 70/40,T 37.5, on Levophed gtt, with acute kidney injury (AKI), encephalopathy” is documented on admission. Within the progress notes is documentation of “Presumed sepsis with all cultures negative at 72 hours.” Can you please clarify use of the term “sepsis” as follows?

    The patient has a diagnosis of sepsis

    The patient is still being evaluated for a diagnosis of sepsis, the diagnosis has yet to be confirmed

    The patient has clinical indicators of sepsis, but a diagnosis of sepsis has been ruled out

    The clinical indicators of sepsis are clinically insignificant, the patient only has a (state the local infection)

    Unable to determine

If sepsis is confirmed, then I would query for the cause of the sepsis if it has not already been documented. That will be the principal diagnosis followed by the code for sepsis. In this particular case, severe sepsis seems supported by the AKI and encephalopathy as long as the provider links those “organ failures” to the sepsis process. Per the ICD-10 Official Guidelines for Coding and Reporting, if the causal organism [of sepsis] is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection.

Here is a sample of such a query to support severe sepsis (sepsis with associated) organ failure:

The diagnosis of sepsis appears within the progress notes on _____. The diagnosis of acute renal failure was documented today. Is there a relationship between the sepsis and acute renal failure?

    No, there is not a relationship

    Yes, the acute renal failure is secondary to the sepsis

    Unable to determine

    Other _______________________________

MD: _________________         Date/time: _______

As a CDI specialist, you should make sure there is clinical evidence to support the diagnosis of sepsis, which it appears you do have in the above scenario. If, in fact, the provider is making the diagnosis of sepsis (which is really what we are attempting to clarify in this scenario) then the CDI specialist needs to establish the type of sepsis (e.g., sepsis, severe sepsis, or septic shock). Once we have established sepsis as a valid diagnosis, we need the documentation to state if the condition was present on admission and, therefore, should be considered as the principal diagnosis (systemic infection trumps local infection). If it occurred following admission it should be reported as a secondary diagnosis.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question which was originally published on the ACDIS Blog. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.