Part of the January 2019 Quest newsletter
With the implementation of ICD-10, there is an increased need to document specific details related to many diagnoses. It’s important to remember that bacteremia, sepsis, severe sepsis, and septic shock are not synonymous. We’ve compiled a few helpful hints and examples to ensure accurate sepsis clinical coding.
Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction is represented by an increase in the sequential (sepsis-related) organ failure assessment (SOFA) score (see table below) of 2 or more points. When baseline values are unknown, they should be assumed to be normal.
Septic shock: A subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone. Patients can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure ≥ 65 mmHg and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.
- Despite adequate fluid resuscitation,
- Vasopressors required to maintain MAP > 65 mmHg and
- Serum lactate level > 2mmol/L
qSOFA (quick SOFA): A simplified version of SOFA. Any two of the following criteria identifies patients at risk for poor outcomes.
- Hypotension (SBP < 100 mmHg)
- Respiratory rate (>22 breaths per minute)
- Alteration in mental status
Bacteremia: The presence of viable bacteria in the blood
Systemic inflammatory response syndrome (SIRS): The body’s systemic response to infection or non-infectious causes
- Temperature >38 or <36 degrees C
- Heart rate >90/min
- Respiratory rate >20/min or PaCO2 <32mmHg
- WBC >12k or <4k or >10% bands
ICD-10-CM coding and documentation needs
- Sepsis: Document sepsis and include the criteria met to arrive at the diagnosis and the infection type, if known. Include how the condition is being monitored, evaluated, and/or treated. In most circumstances an underlying infection can be confirmed, but it is not unusual to see cases of sepsis where a localized infection is not identified especially in immunocompromised patients or those on chemotherapy. Include clear documentation regarding whether the condition was present on admission (POA).
- Septic shock: Document septic shock and include documentation of clinical indicators such as hypotension, despite fluids and treatment, noting how the condition is being monitored, evaluated, and/or treated.
- Hypotension despite fluids and treatment is not synonymous with septic shock; the two terms are not interchangeable, and each have unique ICD-10-CM codes.
Here are three examples of documentation of sepsis that would need to be updated according to the guidelines. Coding compliance:
Sepsis documentation which states: “Concern for sepsis.” This documentation would need clarification:
Patient admitted thru emergency room with the diagnosis of “Due to concern for sepsis,” from unknown source, broad spectrum antibiotics started.” Vital signs: Temperature 38.5, heart rate 120, blood pressure 166/78, pulse oxygenation 92%
- Laboratory values stated: Leukocytosis 12.9 up from 8.4
- Anemia hemoglobin 6.4 down from 7.8
- Lactic acid 2.5
Treatment: Start IV antibiotics and IV fluids
No mention of “sepsis” in the documentation again until day 8 and note states: “Severe sepsis, skin ulcer infection. Lactic acidosis, due to sepsis.”
- LIP wound need to clarify the diagnosis according to the day 8 documentation if clinically significant. “Sepsis due to skin ulcer infection” was present on admission.
- This diagnosis would then need to be carried through to the discharge note again for clarification and accurate documentation.
Sepsis documentation with multiple conditions stated in progress notes that could cause sepsis. This documentation would need clarification.
Patient admitting with vitals on initial presentation: Blood pressure 157/114, temperature 38.9, heart rate 132, Sa02 99%, lactic acid was 1.2.
- She was given 2 liters fluid bolus.
- Dexamethasone 10 mg
- IV Clindamycin
The progress notes then state:
- Acute kidney injury: Could be due to infection and sepsis, NSAIDS but strep can cause glomerulonephritis
Will get urinalysis, run electrolytes, and renal ultrasound.
Start normal saline at 125 cc/hr
Monitor intake/output/daily weights
- Thrombocytopenia most likely due to infection, sepsis
Will get repeat CBC, peripheral smear and coagulopathy studies.
- Active Problems: tonsillitis with strep pharyngitis and Acute kidney injury
There is no statement that specifies Sepsis due to. Query was sent for clarification and MD stated:
Sepsis secondary due to Strep. Pharyngitis – start Penicillin V 500 mg TID.
Recommend outpatient evaluation for possible tonsillectomy.
Being worked up for tonsillectomy at this time.
Sepsis documentation with no supportive documentation in progress notes
Patient admitted through emergency room
- Vital signs: Temperature 36.5, blood pressure 114/72, Sa02-99%, heart rate 110
- Progress notes state: Likely sepsis due to small bowel obstruction
- Sepsis never mentioned again
- Patient did not meet sepsis criteria on admission, so clarification query would be sent.
Pinson, R.D., & Tang, C.L. (2018). Reproduced from 2018 CDI Pocket Guide. © 2017 HCPro, TN., 35 Village Road, Suite 200, Middleton, MA 01949, 800-650-6787. firstname.lastname@example.org. Used with permission.
Singer, e. a. (2016, February 23). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Journal of the Americal Medical Association, 801-810. doi:doi:10.1001/jama.2016.0287.
Contact and more information
Please contact the Clinical Documentation Improvement Department with any questions. Further education regarding this topic is available for your team through the CDI department.
- Jaime Sherman, CDI quality oversight specialist: email@example.com or 319-356-3348
- Deanna Brennan, CDI manager/director: firstname.lastname@example.org or 319-353-7703