Q&A: Clinical Validation of Sepsis

by Cathy Farraher, RN, BSN, MBA, CCM, CCDS & Cheryl Ericson, MS, RN, CCDS, CDIP

Following the release of the “Clinical validation and the role of the CDI professional” white paper, we received the following question from an ACDIS member.

“I encountered clinical validation issues where documentation noted a diagnosis with criteria, but the criteria used didn't meet the definition. For example, noted sepsis with criteria of tachycardia and increased white blood cell (WBC) count. But, the patient’s heart rate (HR) was less than 100 and the WBC was elevated but still less than 12. Should this be clarified with a clinical validation query?”

In the ACDIS white paper, “Coding Clinic for CDI: Addressing and clarifying 2017 Guideline recommendations,” Sharme Brodie, RN, CCDS, CDI Boot Camp instructor based in Middleton, Massachusetts states that,

“Coders have questioned whether ICD-10-CM codes for sepsis may be assigned based on the new clinical criteria that were released in February 2016, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) […] Coding Clinic points readers to the 2017 Official Guidelines for Coding and Reporting when assigning codes for sepsis, severe sepsis, and septic shock, and states that coders must use the most current version of the ICD-10-CM classification along with the Guidelines, and not clinical criteria. Physicians can use whatever criteria they wish to diagnose the patient, but remember, those criteria do not change how the condition will be coded.”

Regardless of whether the practitioner chooses to use Systemic Inflammatory Response Syndrome (SIRS) criteria, sequential organ failure assessment (SOFA) criteria, or some other set of criteria, if the condition is documented and appears to be supported in the record, it can and should be coded without a query.

In the above question, with the limited information we have available to review, perhaps the WBC was trending up quickly, or was already being treated with antibiotics and was trending down. The HR was less than 100, but still met the SIRS guideline of greater than 90. Perhaps the patient also had mental status changes and that had already been documented elsewhere. Without the luxury of a complete review of the record, it is difficult to make a definitive case either for, or against, sending a validation query.

Best practice is for organizations to create a consensus statement defining sepsis. Such a statement would help coders know when to forward the case to CDI for clinical validation as well as help the CDI specialist determine whether the organizational criteria for a diagnosis of sepsis is met.

The consensus statement should not only define sepsis and severe sepsis, but also provide guidance regarding documentation of “early” sepsis or “meets sepsis criteria.” Specifically, it is not always clear if this type of documentation is making a diagnosis or merely an observation. It is also important to remember that both CDI and coding should not only look for clinical indicators supporting the diagnosis of sepsis, but also consider what treatment was rendered.

Not only should sepsis meet criteria as a reportable diagnosis, but it would also be helpful for CDI specialists to understand the Hospital Inpatient Quality Measure requirements of the early management bundle for severe sepsis/septic shock, as such these measures are driving many hospital’s efforts to quickly identify and treat severe sepsis cases. Verifying these criteria are met with the diagnosis of severe sepsis can help the CDI specialist determine if the diagnosis requires additional clinical validation or not.

Editor’s note: Cathy Farraher, RN, BSN, MBA, CCM, CCDS, a CDI specialist at Newton-Wellesley Hospital in Newton, Massachusetts, and Cheryl Ericson, MS, RN, CCDS, CDIP, is manager of clinical documentation services at DHG Healthcare in the Charleston, South Carolina area. Both Ericson and Farraher are members of the CDI Practice Guidelines Committee, and serve as committee chair and chair-elect, respectively. If you have a question for the committee, email ACDIS Editor Linnea Archibald (larchibald@acdis.org). 

Copyright Association of Clinical Documentation Improvement Specialists (ACDIS).  Article reprinted with permission.