Wednesday, January 23, 2019

Sepsis 3 Criteria

Questions have arisen regarding coding for sepsis, as it appears that some payers will begin reviewing records using the new sepsis criteria.  This will undoubtedly create denial issues as the guidelines for the coding of sepsis differ from the new clinical criteria for sepsis.  Let’s examine this confusing issue in more detail in this edition of “In the kNOW”.
 First, here are the definitions of sepsis: 
(OLD) Sepsis is the result of a host’s systemic inflammatory response syndrome (SIRS) to infection.  Severe sepsis is sepsis with organ dysfunction.
(NEW) Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection.

By comparing the two, it is evident that under the new definition, the term severe sepsis has been incorporated into the definition of sepsis.  That presents coders with a quandary as our current coding system calls for coders to assign codes separately for sepsis or severe sepsis.  So what’s a coder to do?

Well, as always it is imperative to use official coding resources available to determine the best course of action.  In this case, Coding Clinic, has addressed this issue in both the 3rd and 4th quarter 2016 editions.  In both instances, Coding Clinic clearly states that coders are not to assign codes based on clinical criteria.  It doesn’t matter what set of criteria (old, new, physician clinical judgment) is used to arrive at a diagnosis.  Instead, coding professionals need to focus on the documentation in the record, and then use the Official Guidelines for Coding and Reporting to select the correct codes.  Coding professionals must work within the classification system as it exists at the time they are assigning the codes, and currently that means still coding sepsis, severe sepsis, and septic shock as appropriate.  

Does that mean that facilities and payers will abide by the same decision?  Certainly not.  Facilities and payers may have their own criteria that physicians are expected to use to arrive at a diagnosis of sepsis.  So what options are there? 

First, clinical documentation improvement specialists (CDIs) should be involved with the physicians to educate them on the new criteria and provide insight into documentation practices that can capture the essence of the new definition and allow the coding staff to assign the proper sepsis coding.  This could be as simple as stating “severe sepsis” or “sepsis with acute sepsis-related organ dysfunction”.  To mitigate potential denials, physicians would be wise to document the clinical indicators that support both the sepsis and organ dysfunction.  By “marrying” the diagnoses, for example: encephalopathy due to sepsis, it provides context for the sepsis diagnosis and gives coding professionals the ability to assign the appropriate codes.

Second, electronic health record systems (EHR) may have the capacity to assist with capturing the documentation necessary to validate sepsis and refute denials.  By capturing the SOFA score (Sequential [Sepsis-Related] Organ Failure Assessment Score) criteria or the quick SOFA score criteria and providing them in an easily accessible report, EHRs can help support the clinical decision for the sepsis coding and be used to substantiate that decision if a denial has been received. 

Third, queries may be used to clarify the sepsis diagnosis.  Ideally, the diagnosis of sepsis is documented throughout the chart, not just once.  CDI specialists should query concurrently, but should there still be confusion once the coding professional is reviewing the chart, a retrospective query should be initiated.  Remember that clinical validation is not the same as DRG validation, and that coding professionals are not the appropriate staff to perform a clinical validation review.

For the time being, coders must continue to code for sepsis within the boundaries of today’s ICD-10-CM classification.  However, it is imperative that coders continue to monitor the classification’s updates to see if, at some point in the future, the classification makes a change to mirror coding with the new clinical guidelines.

Now you are In the

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

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