Learning Objectives Respiratory Failure Acute Respiratory Failure

Sepsis: 1, 2, 3, RAC Attack! Respiratory Failure: Definition and Sequencing Guidelines

William Haik, MD, FACCP, CDIP, AHIMA‐Approved ICD‐10‐CM/PCS Trainer Director DRG Review, Inc.

Fort Walton Beach, FL1

Learning Objectives

• At the completion of this educational activity, the learner will be able to: – Identify the clinical elements that validate the reporting of acute respiratory failure – Identify the clinical criteria that support Sepsis‐1, Sepsis‐2, and Sepsis‐3 definitions

Respiratory Failure

Severe Hypoxia ↓

Pulmonary Acute Respiratory Insufficiency Insufficiency → Respiratory ← Failure

↑ Respiratory Acidosis

• Respiratory failure should be specified as acute, chronic, or acute on chronic (hypoxemic/hypercapneic).

Acute Respiratory Failure

• Respiratory failure is a condition categorized by inadequate exchange of oxygen and/or carbon dioxide by the lungs. • The diagnosis of respiratory failure is a life‐threatening disorder requiring aggressive management and monitoring. A patient with acute respiratory failure usually exhibits evidence of increased work of breathing (rapid respiratory rate, use of accessory muscles of respiration) or possibly cyanosis and/or paradoxical breathing. • Treatment includes frequent respiratory therapy and possibly support with either invasive mechanical ventilation or noninvasive modalities such as CPAP/BiPAP and/or high flow oxygen therapy (HFT). The absence of mechanical ventilation, however, does not exclude the diagnosis of acute respiratory failure.

Respiratory Failure

4. Arterial blood gas determinations are helpful in determining acute respiratory failure.

a) A patient with acute respiratory failure with previously normal lungs • pO2 < 60 mmHg, pCO2 > 50 mmHg, pH < 7.35 on room air (FiO2 = 21%) • Hemoglobin oxygen saturation < 90% on room air (FiO2 = 21%) • P/F ratio (pO2/FiO2) < 300 (Example: pO2 of 90 mmHg on 32% oxygen) P/F = 90/0.32 = 281 b) Acute respiratory failure in a patient with previously abnormal lungs such as chronic obstructive lung disease • pH < 7.35 with a pCO2 > 50 mmHg • Generally, in a patient with chronic lung disease, the arterial blood pH is a more useful criteria than simply efollowing th pCO2 • A change in the pO2 < 60 mmHg representing a drop of 10–15 mmHg from the previous "normal" pO2

Respiratory Failure

c) Oxygen delivery device conversion to FiO2 (estimate based on normal tidal volume) • Nasal O2

1 L 24% 2 L 28% 3 L 32% 4 L 36% 5 L 40% 6 L 44%

• Simple mask 5–8 LPM FiO2 0.35 to 0.55

• Venturi mask Variable LPM FiO2 0.24 to 0.50

• Partial rebreather 10 LPM FiO2 0.50 to 0.70

• Non‐rebreather 15 LPM FiO2 0.70 to 1.0 7 7

Respiratory Failure

d) Hemoglobin oxygen saturation conversion to pO2* Hemoglobin oxygen Partial pressure of saturation oxygen 50% 27 mmHg 75% 40 mmHg 88% 55 mmHg 90% 60 mmHg 98% 100 mmHg

*Hemoglobin oxygen saturation conversion to pO2 is only an approximation as several factors such as pH, temperature, and DPG content may impact it.

References: Murray and Nadel’s Textbook of Respiratory Medicine, Sixth Edition, pp. 1723, 1740. Guyton and Hall Textbook of Medical Physiology, 12th Edition, Chapter 39.

Respiratory Failure

• Chronic Respiratory Failure – No significant deviation from baseline ABGs – pO2 < 60 mmHg – Without significant increase in work of breathing – Continuous oxygen use or ventilatory support – P/F ratio not useful • The cause(s) of the respiratory failure such as COPD, intestinal lung disease, bronchiectasis, etc. should be clearly stated.

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 3 These materials may not be copied without written permission. Respiratory Failure Sequencing Guidelines • Do not code acute respiratory failure as the principal diagnosis when there is a chapter‐specific coding guideline (sepsis, obstetrics, poisoning, HIV, newborn) or an Alphabetic Index or Tabular List directive that takes precedence over the general respiratory failure guidelines and examples listed above. Examples: – Acute respiratory failure, secondary to Pneumocystis carinii pneumonia in a patient with HIV. The human immunodeficiency virus (B20) is reported as the principal diagnosis. – Patient is admitted with acute respiratory failure secondary to Valium overdose. The poisoning (Valium overdose) is reported as the principal diagnosis. – A patient is admitted with aspiration pneumonia with associated sepsis and acute respiratory failure. Sepsis is reported as the principal diagnosis.

Sepsis

• None of these SIRS terms code to ↓ sepsis • Blood cultures do not define sepsis • SIRS has infectious Bacteremia Urosepsis as well as non‐ → Sepsis ← infectious etiologies • “SIRS due to infection” does not ↑ equate to sepsis in Sepsis ICD‐10‐CM Syndrome

Sepsis

A. Infection (B99.9): Invasion of normally sterile tissue, fluid, or body cavity by pathogenic microorganisms B. Bacteremia (R78.81): A laboratory finding of viable bacteria in the blood without evidence of a systemic inflammatory response. C. Systemic Inflammatory Response Syndrome (SIRS) (R65.10): A syndrome defined by the presence of two or more of the following features of systemic inflammation:

1. Fever (core temperature > 38.3°C or 100.9°F) or hypothermia (core temperature < 36°C or 96.8°F) 2. Leukocytosis (white count > 12,000) or leukopenia (white count < 4,000 or > 10% bands) 3. Tachycardia (> 90 beatsr pe minute or more than two SD above the normal value for age)

4. Tachypnea (respiratory rate > 20 breaths per minute or a pCO2 of < 32 mmHg)

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 4 These materials may not be copied without written permission. Sepsis D. Sepsis (A41.9): An infection‐induced syndrome defined by the presence of at least two unexplained features of systemic inflammation: 1. Fever (core temperature > 38.3°C or 100.9°F) or hypothermia (core temperature < 36°C or 96.8°F) 2. Leukocytosis (white count > 12,000) or leukopenia (white count < 4,000 or > 10% bands) 3. Tachycardia (> 90 beats per minute or more than two SD above the normal value for age) 4. Tachypnea (respiratory rate > 20 breaths per minute or a pCO2 of < 32 mmHg) 5. Altered mental status 6. Significant edema or positive fluid balance (> 20 mL per kg over 24 hours) 7. Hyperglycemia, unexplained (glucose > 140 mg/dL in the absence of diabetes) 8. Evidence of hypoperfusion [hyperlactatemia (> 1 mmol/L)] or decreased capillary refill or mottling 9. Ileus (absent bowel sounds) 10. Arterial hypoxemia (PaO2/FiO2 < 300) 11. Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs, despite adequate fluid resuscitation) 12. Creatinine increase > 0.5 mg/dL or 44.2 umol/L 13. Hyperbilirubinemia (> 2 mg/dL)* 14. Plasma C‐reactive protein more than two SD above the normal value 15. Plasma procalcitonin more than two SD above the normal value

Sepsis

E. Septicemia (A41.9): An antiquated, ambiguous term that has been used nonspecifically in the past to imply either bacteremia or sepsis; therefore, should be eliminated from current medical usage. F. Severe sepsis (R65.20): Defined as sepsis‐induced tissue hypoperfusion or organ dysfunction (any one of which due to infection): 1. Sepsis‐induced hypotension [systolic blood pressure (SBP) < 90 mmHg, mean arterial pressure (MAP) < 70 mmHg, or an SBP decrease by > 40 mmHg in adults or less than two SD below normal for age] 2. Lactate above upper limits of laboratory normal 3. Acute oliguria (urine output < 0.5 mL/kg/hrr fo more than 2 hrs, despite adequate fluid resuscitation) 4. Creatinine increase > 2.0 mg/dL 5. Platelet count < 100,000/uL 6. Coagulopathy (international normalized ratio > 1.5)

7. Acute lung injury with PaO2/FiO2 < 250 in the absence of pneumonia as an infection source

8. Acute lung injury with PaO2/FiO2 < 200 in the presence of pneumonia as an infection source 9. Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL*)

Sepsis

G. Septic shock (R65.21): Severe sepsis with hypotension (systolic blood pressure < 90 mmHg or a 40 mmHg drop from the previous normal blood pressure) unresponsive to fluid resuscitation, requiring vasopressor intervention.

*Personal email communication with Mitchell M. Levy, MD, on May 14, 2013. Bilirubin levels for sepsis and severe sepsis were reversed with additional modifications to the clinical elements also ebased on th communication.

References: Dillinger, Levy, et al., “Surviving Sepsis Campaign, 2012,” Critical Care Medicine, 2013;41(2). Levy, M.D., M.M., “International Sepsis Definition Conference, 2001,” Critical Care Medicine, 2003;31:1250–1256. Bone, M.D., R.C., “ACCP/SCCM Consensus Conference,” Chest, 1992;101:1044–1055.

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 5 These materials may not be copied without written permission. The Third International Consensus Definition for Sepsis and Septic Shock (Sepsis‐3) • Since the previous consensus definitions of sepsis1, 2 and its related terminology (sepsis syndrome, septicemia, severe sepsis, and septic shock), there have been considerable advances in pathobiology • Therefore, a third international consensus definition representing experts from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine published the following updated definitions in the February 2016 Journal of the American Medical Association3

16 16

A. Sepsis is defined as a life‐threatening organ dysfunction caused by a dysregulated host response to infection that results in an overall mortality risk of approximately 10% in a general hospital population with presumed infection. • SIRS criteria were considered unhelpful and may simply reflect an appropriate adaptive host response to an infection. • The organ dysfunction must be identified as an acute change from the baseline in the Sequential Sepsis‐related Organ Failure Assessment (SOFA) score of ≥ 2 (see Table 1). The baseline can be assumed to be zero in patients not known to have pre‐existing organ dysfunction. • Based on the above definition of sepsis, the term severe sepsis is superfluous. • Unlike the 2012 Surviving Sepsis definition4, an exacerbation of organ dysfunction may result from local infection5, as these patients were not excluded from the Sepsis‐3 consensus definition.

Table 1 Sequential Sepsis‐related Organ Failure Assessment (SOFA) Score

Score System 012 34 Respiration < 100 (13.3) PaO2/FIO2, < 200 (26.7) with with ≥ 400 (53.3) < 400 (53.3) < 300 (40) mmHg (kPa) respiratory support respiratory support Coagulation Platelets, ×1000/μL ≥ 150 < 150 < 100 < 50 < 20 Liver Bilirubin, mg/dL < 1.2 (20) 1.2–1.9 (20–32) 2.0–5.9 (33–101) 6.0–11.9 (102–204) > 12.0 (204) (μmol/L) Cardiovascular Dopamine > Dopamine < 5 or 15 or MAP ≥ 70 mmHg MAP < 70 mmHg dobutamine (any Dopamine 5.1–15 epinephrine > dose) 0.1 or or epinephrine ≤ 0.1 norepinephrin e > 0.1 or norepinephrine ≤ 0.1 Central Nervous System Glasgow Coma Scale 15 13–14 10–12 6–9 < 6 Renal Creatinine, mg/dL < 1.2 (110) 1.2–1.9 (110–170) 2.0–3.4 (171–299) 3.5–4.9 (300–440) > 5.0 (440) (μmol/L) 18 Urine output, mL/d < 500 < 200 18

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 6 These materials may not be copied without written permission. B. Quick SOFA (qSOFA) is a term incorporating: • Altered mentation • Systolic blood pressure of ≤ 100 mmHg • Respiratory rate ≥ 22/minute • Any two of three clinical variables that have a similar predictive validity as a full SOFA score outside the ICU • The qSOFA is only intended as a screen to prompt the clinician to investigate further for organ dysfunction6

C. Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase hospital mortality in excess of 40%. • Septic shock is identified in patients with persisting hypotension requiring vasopressors to maintain MAP to ≥ 65 mmHg and have a lactic acid level of ≥ 2 mmol/L (18 mg/dL), despite adequate volume resuscitation • The combination of hypotension and hyperlactatemia encompasses both cardiovascular compromise and cellular dysfunction, identifying a group of patients with particularly higher mortality than either entity alone • In settings where lactate measurement is unavailable, other criteria may be substituted to represent tissue hypoperfusion, such as delayed capillary refill

D. Septicemia, sepsis syndrome, and urosepsis were addressed in the present and past consensus statements and for various reasons should not be utilized to describe sepsis or its related conditions.

References: 1 Bone, M.D., R.C., “ACCP/SCCM Consensus Conference,” Chest, 1992;101:1044–1055. 2 Levy, M.D., M.M., “International Sepsis Definition Conference, 2001,” Critical Care Medicine, 2003;31:1250–1256. 3 JAMA, 2016; 315(8):757–759; 762–774; 775–787; 801–810. 4 Dillinger, Levy, et al., “Surviving Sepsis Campaign, 2012,” Critical Care Medicine, 2013;41(2). 5 Personal e‐mail communication with Christopher W. Seymour, M.D., MSc. 6 Ibid.

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. 7 These materials may not be copied without written permission. Abridged Comparison of Severe Sepsis/Septic Shock Definitions

Sepsis‐1 and 2 Sepsis: An infection‐induced Severe sepsis: Defined as sepsis‐induced Septic shock: Severe sepsis with syndrome defined by the tissue hypoperfusion or organ dysfunction hypotension (systolic blood pressure < References: presence of at least two (any one of which due to infection): 90 mmHg or a 40 mmHg drop from the unexplained features of previous normal blood pressure) 1. Bone, M.D., R.C., ACCP/SCCM systemic inflammation • Lactate above upper limits of laboratory unresponsive to fluid resuscitation, Consensus Conference, Chest, normal requiring vasopressor intervention

1992; 101:1044–1055. • Acute lung injury with PaO2/FiO2 < 250 in 2. Levy, M.D., M.M., the absence of pneumonia as an “International Sepsis Definition infection source

Conference, 2001,” Critical Care • Acute lung injury with PaO2/FiO2 < 200 in Medicine, 2003; 31:1250–1256. the presence of pneumonia as an infection source Sepsis 3 Organ dysfunction identified Septic shock is identified in patients as an acute change from the with persisting hypotension requiring References: baseline in the SOFA score vasopressors to maintain MAP to ≥ 65 of ≥ 2. mmHg and have a lactic acid level of ≥ 2 JAMA, 2016; 315(8):757–759; N/A mmol/L (18 mg/dL), despite adequate 762–774; 775–787; 801–810 An exacerbation of organ volume resuscitation dysfunction may result from local infection.*

*Personal e‐mail communication with Christopher W. Seymour, M.D., MSc. Sep‐1 #0500 NQF 1. Creatinine increase > 2.0 mg/dL or urine 1. Documentation of severe sepsis output < 0.5 mL/kg/hr for 2 consecutive AND Version 5.2a hours 2. Tissue hypoperfusion after fluid 2. Total bilirubin > 2 mL/dL resuscitation as evidenced by either Discharges 01/01/17–12/31/17 N/A 3. Platelet count < 100,000/uL 4. INR > 1.5 or aPTT > 60 sec ‐ systolic blood pressure < 90 5. Lactate > 2 mmol/L (18.0 mg/dL) ‐ mean arterial pressure < 65 6. Documentation of acute respiratory ‐ decrease in systolic blood pressure failure by > 40 from the previous normal AND blood pressure Invasive mechanical ventilation or non‐ OR invasive mechanical ventilation (BiPAP or 3. Lactic level ≥ 4 mmol/L CPAP) 22

RAC Attack

• Audit Criteria • Hospital Defense: – Traditional Medicare: Sepsis not clinically validated . The provider’s statement the patient has a particular condition is sufficient – Medicare Advantage: Validated with Sepsis‐3 criteria . ICD‐10‐CM Alphabetical Index entry sepsis, with organ dysfunction—R65.20 • RAC Offense: o ICD‐10‐CM Official Guidelines for Coding and . “a facility or a payor may require the physician use a Reporting, FY 2017, pp. 12–13 particular clinical definition/criteria when . CMS: No plans to change definition in the CMS SEP‐1 establishing a diagnosis ...” Quality Measure • AHA’s Coding Clinic for ICD‐10‐CM, Fourth o Journal of the American Medical Quarter 2016, pp. 147–149 Association, July 2016, Volume 316 Issue 4, . Clinical validation is a separate function from the pp. 457–458 coding process . Sepsis 3 Would Only Identify Sicker Patients That Would Delay Treatment o Recovery Audit Contractor Scope of Work o America Journal of Respiratory and Critical Care Medicine, July 01, 2016, editorial – Surviving Sepsis 2016 Campaign Definition (without . SIRS better than qSOFA as a screen in the emergency criteria) seems to promote Sepsis‐3 room for sepsis o Journal of the American Medical o Chest, July 17, 2016 Association, March 2017, Volume 45, p. 4 • Caveat . qSOFA (Sepsis‐3) is better at predicting hospital • Final adaptation of criteria up to the individual mortality and increased ICU LOS RSthan SI medical staff while awaiting other confirmatory o Journal of the American Medical studies Association, January 2017, Volume 317 Issue 3, pp. 267–308

Internal Escalation Policy

• “When the question of clinical validity is identified in practitioner documentation, the facility may wish to follow their internal escalation policy rather than requiring the CDI specialist/coder to query the practitioner.” – Querying for a lack of clinical validity is a sensitive matter and may negatively impact the relationship between the coder/CDI and practitioner, so organizations may consider relegating these types of queries to the coding/CDI supervisor or manager

References: AHIMA Journal, July 2016, Clinical Validation: The Next Level of CDI. AHIMA Journal, February 2013, Guidelines for Achieving a Compliant Query Practice.

Thank you. Questions?

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