Admitted with Sepsis, Pneumonia, and Respiratory Failure

was caused by another respiratory condition (not caused by the sepsis) then it may be appropriate to sequence Sepsis (Part 2) Several respiratory failure as the principal diagnosis. RAC denials Issue 2 August/September 2011 have shown that there may be confusion Content regarding the sequencing Sepsis (Part 2) of sepsis with other conditions. The following is New RAC Issues suggested advice to follow when coding or querying for these types of records: Current RAC Audit Request

If the patient is admitted with both pneumonia and sepsis, sequence sepsis as the principal diagnosis (AHA Coding Clinic 2003, fourth quarter, pages 79-81). If the patient is admitted with both pneumonia and respiratory failure, sequence respiratory failure as the principal diagnosis (AHA Coding Clinic 2003, second quarter, pages 21-22).

If the patient is admitted with respiratory failure due to or associated with an acute non-respiratory condition (such as sepsis), then the acute non-respiratory condition (i.e. Sepsis) is sequenced as the principal diagnosis. And since respiratory failure is an organ dysfunction of SIRS/sepsis, it should be listed as a secondary diagnosis (AHA Coding Clinic 1991, second quarter, pages 3-5).

Following this logic, if a patient is admitted with all three - sepsis, pneumonia, and respiratory failure - then the sepsis will more than likely be sequenced as the principal diagnosis as it is the acute condition causing the respiratory failure. However, look closely at the record, if the documentation specifically supports that the respiratory failure Continued on page 2 Sepsis/Severe Sepsis/SIRS with a Localized Infection end with the suffix “-itis” that many assume to be infections, such as cellulitis, diverticulitis, orchitis, RAC Denial: H&P and discharge summary indicate the patient was admitted with both sepsis and cellulitis. Progress notes indicate the cellulitis was the cause of the sepsis. Even though both conditions were present on admission, we cannot choose between the two as PDX in this case because the coding rules indicate that we must sequence the code for sepsis as principal diagnosis. The underlying localized infection (cellulitis) is the secondary diagnosis.

cholangitis, and the like, are not infections unless the physician explicitly states that these are infections. If the reason for admission is sepsis (or severe sepsis or (AHA Coding Clinic 2010, first quarter, p. 10) SIRS) and a localized infection (such as cellulitis, pyelonephritis, pneumonia, meningitis, cholangitis, Sepsis and Aspiration Pneumonia peritonitis, etc), the code for the systemic infection (e.g., The Official Guidelines for Coding and Reporting 038.X, 112.5, etc), is sequenced first, followed by code regarding two or more diagnoses that equally meet the 995.91 or 995.92, and then the code for the localized definition for principal diagnosis state, "In the unusual infection. instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the However, look closely at the record, if the circumstances of admission, diagnostic workup and/or documentation specifically supports that the patient is therapy provided, and the Alphabetic Index, Tabular admitted for the localized infection and the patient List, or another coding guidelines does not provide develops sepsis/severe sepsis/SIRS after admission, the sequencing direction, any one of the diagnoses may be localized infection should be sequenced first, followed sequenced first." by the code for the systemic infection (e.g., 038.X, 112.5, etc), and then 995.91 or 995.92 as secondary When Sepsis and aspiration pneumonia are both present diagnoses. Query the physician if it is not clear if the on admission, and neither one is ruled out during the sepsis was present on admission or developed later. stay, and both were treated, coders can choose either sepsis or aspiration pneumonia as the PDX. Before Query the physician if the documentation does not link assigning one or the other as PDX, it is the Coder’s or the localized infection to the sepsis, severe sepsis, or Documentation Specialist’s responsibility to query the SIRS. Remember - SIRS codes to sepsis only when it is physician to determine if the aspiration pneumonia is the linked to an infection. While the ICD-9-CM Official local source of the sepsis. Coding guidelines state that Guidelines allow for pneumonia and urinary tract the localized infection which entered the blood stream infection to be designated as infections (which, for must be a secondary diagnosis. If the physician pneumonia, is not always the case), other conditions that indicates that the local source of the sepsis is the 2 aspiration pneumonia, code the sepsis as PDX and the aspiration pneumonia as secondary DX. If the aspiration Sepsis due to chronic cholecystitis and pneumonia is the not the cause of the sepsis, it can be cholecystectomy performed considered as a principal diagnosis. The physician should add an addendum clearly stating there is no link. Chapter specific guidelines take precedence over general coding guidelines (AHA Coding Clinic 2003, first quarter, page 15). Therefore, since the sepsis guidelines are chapter-specific guidelines, the sepsis should be sequenced as the principal diagnosis when a patient is admitted with sepsis due to chronic cholecystitis.

Septic arthritis with sepsis Septic arthritis is an infection contained to the affected area. It is not a truly septic condition. A patient with

RAC Denial: Cases also are being denied when a patient has "bacteremia," "sepsis," and "urosepsis" documented in the medical record but only "urosepsis" is documented on the discharge summary. In this case, query the physician to clarify which diagnosis was made after study.

septic arthritis may not have sepsis. However, it is possible to also have septic arthritis with sepsis. Therefore, if the patient presents with both septic arthritis and sepsis, then it would be appropriate to sequence the sepsis as the principal diagnosis.

Urosepsis and Sepsis due to urinary tract infection

Sometimes the clinical side and the coding side don’t match up. A classic example is urosepsis, which to a physician means “a patient who has a urinary tract infection who also is septic or likely to be septic”. But the documentation guidelines don’t allow for this definition of urosepsis. In the coding guidelines, urosepsis means just a simple UTI. So the physician actually has to write UTI with sepsis. That doesn’t make any sense from a clinical standpoint!

Even so, the coding guidelines for urosepsis remain the same. If only urosepsis was documented, then code

3 599.0 would be assigned. However, coders and/or documentation improvement specialists should not be satisfied with coding UTI for a diagnosis of Urosepsis if the documentation contains clinical signs of septicemia: In those cases where a UTI and a urinary catheter are both present but not linked by the physician, it is always  Fever, chills, malaise, hypotension, tachycardia, right for the Coder or CDI Specialist to query the tachypnea, confusion, altered mental status physician to clarify whether or not the UTI was due to  IV broad spectrum antibiotic and push fluids the catheter. Don’t leave money on the table for your  Leukocytosis/leukopenia (WBC less than 3,000 organization! or more than 12,000)  Blood culture may be positive or negative  LOS often is greater than 3 days but not Line Sepsis versus Line Septicemia mandatory A diagnosis of septicemia due to a vascular access device requires two codes. The principal diagnosis is It is the Coder or Clinical Documentation Improvement 996.62, infection and inflammatory reaction due to other Specialist’s responsibility to query the physician for vascular device, and a code from category 038, clarification to determine whether urosepsis means the septicemia is sequenced as a secondary diagnosis. patient has septicemia or sepsis with a urinary tract Without the documentation of “sepsis” or “SIRS”, a source or an infection contained within the urinary tract. code from subcategory 995.9, systemic inflammatory Use query form D attached. response syndrome (SIRS), would not be assigned (AHA Coding Clinic 1994 second quarter, page 13). On the other hand, Sepsis due to a vascular access device is assigned code 996.62, infection and inflammatory UTI with Presence of an Indwelling Urinary Catheter reaction due to other vascular catheter followed by the and Septicemia appropriate sepsis code from category 038 and a code from subcategory 995.9, systemic inflammatory Foley catheters are considered indwelling urinary response syndrome (SIRS). If organ dysfunction is catheters; however, so are suprapubic cystostomies, present, codes should be added to identify the specific percutaneous nephrostomies, and internal ureteral stents. type of organ dysfunction (AHA Coding Clinic 2004, Septicemia due to an indwelling urinary catheter is second quarter, page 16). assigned code 996.64, infection and inflammatory reaction due to internal prosthetic device, implant and graft, and is sequenced as the principal diagnosis. A secondary diagnosis code from category 038 and a code for the organism responsible must be assigned, if not indicated by the septicemia code, and sequenced as a secondary diagnosis (AHA Coding Clinic 1993, third quarter, page 6.)

4 RAC Denial: An underpayment determination was made by the RAC in a case where Septicemia was due to an UTI and the UTI was documented as due to an indwelling urinary catheter. Septicemia was submitted as the PDX. The RAC correctly re-coded the case with 996.64 as the PDX resulting in a higher paying DRG.

5 Septicemia due to Gastrostomy Infection Biliary Septicemia due to Percutaneous Transhepatic Septicemia due to an infection of a gastrostomy is Cholangiogram assigned code 536.41 plus 038.x. (AHA Coding Clinic 1998, fourth quarter, pages 42 and 43.) Biliary septicemia due to percutaneous transhepatic cholangiogram is assigned code 998.59, other Septicemia due to Colostomy and Enterostomy postoperative infection and 038.x, septicemia (AHA Infection Coding Clinic 1995, second quarter, page 7).

Septicemia due to an infection of a colostomy or Nadir sepsis enterostomy is assigned code 569.61, infection of colostomy and enterostomy plus 038.x, septicemia Nadir sepsis is assigned code 038.9, unspecified (AHA Coding Clinic 1998 fourth quarter, page 44). septicemia, followed by code 288.0, neutropenia (AHA Coding Clinic 1996 third quarter, page 6). Staph Aureus Septicemia due to Tracheostomy Site Infection

Septicemia from an infected tracheostomy site due to Staphylococcus aureus is assigned code 519.11, infection of tracheostomy and 038.11, Staphylococcus aureus septicemia (AHA Coding Clinic 1998 fourth quarter, page 42).

Sepsis due to a Postprocedural Infection

Documentation of causal relationship must exist in the medical record. As with all postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the infection and the procedure. In cases of postprocedural sepsis, the complication code, such as code 998.59, Other postoperative infection, or 674.3x, Other complications of obstetrical surgical wounds should be coded first followed by the appropriate sepsis codes (systemic infection code and either code 995.91or 995.92). An additional code(s) for any acute organ dysfunction should also be assigned for cases of severe sepsis.

6 Neutropenic sepsis

Neutropenic sepsis is assigned code 038.9, unspecified septicemia, followed by neutropenia, 288.0 (AHA Coding Clinic 1996, second quarter, page 6).

New RAC Issues The recovery audit contractors must have new issues approved by CMS before they can start sending out record requests. CGI is our regions recovery audit contractor. CGI has added the following new issues this summer:

MS-DRGs 255-257 Upper limb and toe amputations for circulatory disorders

MS-DRGs 280-285 Acute myocardial infarction

MS-DRGs 288-290 Acute and subacute endocarditis

MS-DRGs 294-295 Deep vein thrombophlebitis

MS-DRGs 296-298 Cardiac arrest

MS-DRGs 299-301 Peripheral vascular disorders

MS-DRGs 332-334 Rectal resection

MS-DRGs 338-343 Appendectomy

MS-DRGs 344-346 Minor small and large bowel procedures

MS-DRGs 347-349 Anal and stomal procedures

MS-DRGs 408-410 Biliary tract procedures

MS-DRGs 420-525 Hepatobiliary procedures

MS-DRGs 559-561 Aftercare musculoskeletal system

MS-DRGs 641-645 Nutritional and endocrine disorders

MS-DRGs 969-970 and 974-977 Human Immunodeficiency virus infections

7 Current RAC Audit

RAC Audit July 2011

We received a request for 196 records from 7 acute care facilities on 35 different issues.

The top 5 requests for DRG included:  MS-DRG 216-221 – Cardiac Valve and Other Cardiothoracic Procedures (total of 28 records from 3 facilities)  MS-DRG 329-331 – Major Small and Large Bowel Procedures (total of 30 records from 5 facilities)  MS-DRG 335-337 and 350-355 – Lysis of Adhesions (total of 10 records from 3 facilities)  MS-DRG 411-419 – Cholecystectomy (total of 9 records from 4 facilities)  MS-DRG 461-462, 466, 468 and 470 – Major Joint Procedures (total of 8 records from 3 facilities) These requests also are looking for the inpatient admitting order