Does the patient really have sepsis? Experts say coders often struggle with this question because physicians don't sufficiently document clinical indicators.
"[Recovery Auditors] are doing a really good job at identifying the patients who don't have sepsis, and they're taking the money back," says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.
What are Recovery Auditors looking for? They're data mining for sepsis MS-DRGs and then focusing in on those with a short length of stay, particularly when the patient is discharged home, says Gold. Auditors are also looking for specific clinical indicators to support a diagnosis of sepsis, he adds.
"If there are no clinical indicators, auditors are denying payment," says Gold. "One of the things you have to realize is that a patient with sepsis may not have clinical indicators, especially if the patient is immune-compromised. Sometimes the patient will have all of the clinical indicators and not have sepsis, which means you have to look at the fact that perhaps these abnormalities were due to other causes."
Tip 1: Verify that clinical indicators of sepsis are present. The following clinical indicators might indicate a sepsis diagnosis in an adult patient:
- Fever (greater than 100.4°F) or hypothermia (less than 96.8°F)
- Tachypnea
- Tachycardia
- Altered mental status
- Oliguria
- Hypotension
- Metabolic acidosis
- Leukocytosis (white blood cell count of greater than 12,000 cells per cubic millimeter or greater than 10% bands)
- Leukopenia (white blood cell count of less than 4,000 cells per cubic millimeter)
Treatment can include IV antibiotics, vasopressors, activated protein C, corticosteroids for glucose levels, and IV fluids. A physician must document a definitive diagnosis even when these clinical indicators are present, says Gold. Coders may query when these indicators are present but the definitive diagnosis of sepsis is not documented, he adds. However, coders should look at the medical record in its entirety to determine whether the patient is truly sick. For example, if documentation indicates that the patient is awake, alert, and in no distress, sepsis may not be present, he says.
Be leery of documentation that patients are placed on a sepsis protocol in the ER, says Gold. "That does not mean that the patient has sepsis," he says. "This shows that the patient has an infection and is sick enough to be put on the protocol … The patient must be evaluated as to whether or not he or she has sepsis. Sometimes the physician rules it out."
Also note that adult sepsis criteria don't translate to the pediatric population. Pediatric patients have sepsis when two or more of these clinical indicators are present:
- Temperature (less than 96.8°F or greater than 100.4°F orally or rectally)
- Heart rate (greater than 180 beats per minute [bpm] in neonates, greater than 160 bpm in infants 1-12 months, greater than 110 bpm in children 1-11 years, greater than 90 bpm in adolescents and adults)
- Systolic blood pressure (less than 60 mmHg for neonates, less than 70 mmHg for children 1-12 months, less than 70 mmHg +2 [age of child] for children 1-10 years, less than 90 mmHg in adolescents or adults, or has dropped by greater than 40 mmHg from baseline)
- Respiratory rate (greater than 60 breaths per minute in neonates and infants [newborn to 12 months], greater than 40 breaths per minute in older infants and toddlers [1-3 years], greater than 34 breaths per minute in preschool-age children [3-5 years], greater than 30 breaths per minute in school-age children [6-11 years], greater than 20 breaths per minute in adolescents and adults)
- White blood cell count greater than 12,000 cells/mm3, or white blood cell count less than 4,000 cells/mm3, or more than 10% bands
Tip 2: Know that urosepsis and sepsis are not synonymous. ICD-9-CM defines urosepsis as a urinary tract infection (UTI) (599.0). If a physician notes urosepsis—and clinical indicators for sepsis are documented—coders must query the physician for clarification, says Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, a HIM expert in Fremont, Calif.
If a patient has sepsis (038.x) from a urinary source, documentation should state one of the following:
- Sepsis from UTI
- UTI causing sepsis
- Sepsis secondary to a UTI
Note that ICD-10-CM doesn't include the term urosepsis, says Bryant. Encourage physicians to document UTI or be more specific regarding a UTI's link to sepsis, she adds. Clarify whether the generalized sepsis is caused by entry of toxic byproducts into the general vascular circulation or whether the urine is merely infected by bacteria, bacterial byproducts, or other toxic material, without the presence of sepsis.
Tip 3: Look for a link between organ dysfunction and sepsis. Physicians must link any organ dysfunction to sepsis before coders can report severe sepsis (995.92), says Bryant. For example, a physician must document acute respiratory failure due to sepsis or acute liver failure due to sepsis. When the link is not clear, coders should query the physician for clarification, she adds.
Tip 4: Bacteremia is not synonymous with septicemia. Bacteremia (790.7) is a laboratory finding that denotes the presence of bacteria in the blood. Septicemia is an acute illness. Bacteremia may progress to septicemia only when there is a more severe infectious process or an impaired immune system, says Bryant. Coders should query when the two diagnoses are not clearly differentiated, she adds.
Coders can proactively prevent sepsis coding errors by doing the following:
- Run a report of cases with a principal diagnosis of 599.0. Audit these cases to determine whether sepsis may have been present but not documented or coded.
- Run a report of cases with a principal diagnosis of sepsis. Audit these cases to determine whether clinical indicators of sepsis are documented. Also look for secondary diagnoses of pneumonia, cellulitis, or other infectious processes.
- Establish a physician advisor, liaison, or champion who can assist in explaining common documentation issues to physician peers.
- Look at query trends. Run a report of all diagnoses to which your queries pertain. This will allow you to track and trend and find patterns. Excessive queries for sepsis could indicate poor physician documentation patterns that CDI specialists should help address.
Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.