Ask ACDIS: Coding Clinic clarifies SIRS query questions

Q: How should I query for systemic inflammatory response syndrome (SIRS) if SIRS codes to sepsis? I want to correctly query and obtain the proper supporting information in the medical record in the event of an audit. Any discussion on this topic is appreciated.

A: This question raises two issues. First, SIRS does not code to sepsis. SIRS by itself codes to 995.90, Systemic inflammatory response syndrome, unspecified.

SIRS codes to sepsis only when it is linked to an infection. While the ICD-9-CM Official Guidelines for Coding and Reporting allow for pneumonia and urinary tract infection to be designated as infections (which, for pneumonia, is not always the case), other conditions that end with the suffix “-itis” that many assume to be infections, such as cellulitis, diverticulitis, orchitis, cholangitis, and the like, are not infections unless the physician explicitly states that these are infections. Coding Clinic, First Quarter 2010, p. 10, states the following:

Question: Please clarify the Official Guideline for Coding and Reporting SIRS due to noninfectious process. The guideline states that systemic inflammatory response syndrome (SIRS) can develop as a result of certain noninfectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. A physician at our hospital stated that acute pancreatitis is an inflammation of the pancreas that can occur with infection. Acute pancreatitis is usually caused by gallstones or by drinking too much alcohol, but these aren’t the only causes. If the guideline is accurate, could it be applied to other inflammatory conditions, such as diverticulitis, cholangitis, orchitis, et cetera?

Answer: Yes, the guideline for noninfectious SIRS can be applied to other types of inflammatory conditions as well as pancreatitis. Therefore it would be appropriate to report code 995.93, Systemic inflammatory response syndrome due tononinfectious process without acute organ dysfunction, or code 995.94, Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction, for SIRS due to any noninfectious condition.

A more recent answer reaffirming this appears in Coding Clinic, First Quarter 2011, p. 22:

Question: We are requesting clarification of the advice published in First Quarter 2010, page 10, in which coders were instructed to assign code 995.93, Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction for SIRS due to a noninfectious condition, such as pancreatitis. Since the etiology of pancreatitis can either be infectious or noninfectious, shouldn’t the provider be queried? Could Coding Clinic clarify this issue further?

Answer: Pancreatitis can have various etiologies; however, the majority of cases of pancreatitis are noninfectious. In 10-30% of cases, the cause is unknown, although studies have suggested that approximately 70% of idiopathic pancreatitis may be due to biliary microlithiasis. In those rare circumstances where the provider documents SIRS due to infectious pancreatitis, use the infectious SIRS code rather than the noninfectious one. Query the provider regarding the cause of pancreatitis, if the health record documentation is not clear. This advice is consistent with previously published information.

Therefore, SIRS due to any condition that is not explicitly documented to be an infection garners code 995.93 (a CC) or 995.94 (an MCC), depending on whether an acute organ dysfunction is linked to the SIRS. If it was the physician’s intention to state that SIRS was due to infection, the word “sepsis,” defined as SIRS due to infection, is preferred. The physician should use the term “SIRS” only if the intent is to communicate that the SIRS phenomenon is due to a noninfectious disease process.

The second issue addresses how to survive an audit. Sadly, the definition of the term “SIRS” has evolved over the years. Some still hold to the 1992 definition where only two out of four SIRS criteria—primarily representing abnormal vital signs and/or a high or low white count—must be met. This definition and associated criteria are currently not in vogue, given that the inflammatory mediators in SIRS have myriad manifestations and consequences and that each indicator by itself is not specific for the disease.

I agree with Robert Gold, MD, who stated during the May 26 ACDIS quarterly conference call that a combination of abnormal vital signs does not constitute SIRS. One must remember that a “SIRS score” does not mean that the patient has SIRS or sepsis (SIRS due to infection). What must be present are the clinical findings that would lead a seasoned clinician to deduce that the patient is “septic” (has sepsis) or is systemically ill from his or her noninfectious inflammation. A list of these are available on the following websites:

• Sepsis: www.tinyurl.com/2008sepsis
• Noninfectious SIRS: www.tinyurl.com/6yxh3y5

I like what is published in the 2001 International Sepsis Definitions Conference. This references a table similar to that outlined in definition above. It states the following:

It is important to emphasize that none of the findings in Table 1 [in the Definitions document] is specific for sepsis. A high cardiac output is commonly observed following major surgical procedures or multiple traumas. Arterial hypotension can be caused by many conditions other than sepsis, such as acute left ventricular failure secondary to acute myocardial infarction (AMI) or hemorrhage. Coagulopathy can be drug-induced and is associated with many different diseases, in addition to sepsis. It is important that as a practitioner “checks off the boxes” to establish the diagnosis of sepsis; only findings that cannot be easily explained by other causes should be included ... We have not chosen thresholds for each of the criteria that are consistently abnormal in degree. The question is whether thresholds similar in degree of abnormality confer similar prediction in sepsis.

During the deliberations on the signs and symptoms that characterize sepsis, the group turned toward the day-to-day “reality” for bedside clinicians. The group concluded that few, if any, patients in the early stages of the inflammatory response to infection are diagnosed with sepsis via four arbitrary criteria. Instead, the clinician goes to the bedside, identifies a myriad of symptoms, and regardless of an evident infection declares the patient to “look septic.” If no obvious source of infection exists, the clinician then initiates a search for an infectious origin of the signs and symptoms associated with sepsis. The use of the word “some” (Table 1) reflects the clinical reality at the bedside rather than an arbitrary list invented for the purpose of clinical trial entry criteria.

Should the definition of sepsis reflect reality as seen at the bedside, thereby facilitating a clinical diagnosis, or should the definition enable investigators to develop clear and simple entry criteria for clinical trials? It was the opinion of the group that facilitating bedside diagnosis should have primacy over research entry criteria.

Therefore, if a patient has sepsis (SIRS due to infection) or SIRS due to a noninfectious localized inflammation or cause, in order to survive an audit, I believe the following must be true:

• To have sepsis (SIRS due to infection), the following must exist:
  • Evidence that the patient has an infection (e.g., positive culture, prolonged antibiotic use)
  • The physician describes the patient as toxic in appearance or “septic appearing”
  • “Some” (preferably three, or two with a severe organ dysfunction) of the SIRS criteria published in 2008 are met, provided that they are not due to another condition
• To have sepsis (SIRS due to noninfection), the following must exist:
  • Evidence of an underlying cause (Note: Drugs can cause SIRS; however, I would prefer that it be some sort of inflammation, trauma, burn, malignancy, and the like.)
  • At least two (preferably three) of the SIRS score are met, provided that they are not due to another condition
  • The patient appears to be very ill 

Editor’s Note: James S. Kennedy, MD, CCS, managing director at FTI Healthcare in Brentwood, TN, and a member of the ACDIS advisory board, answered this question. He can be reached at james. kennedy@ftihealthcare.com or 615/479-7021.