Sepsis: Understanding the Confusion VHIMA Annual Convention

1. Sepsis: Understanding the ConfusionVHIMA Annual Convention April 24, 2008 Donna Stickley, MD, FACEP

2. Objectives Understand the terminology Epidemiology Diagnosis and Treatment Coding Considerations

3. Definitions Key to Understanding 

4. Escape Key

5. Consensus Conference 1991 Consistent definition for sepsis Tools for improving detection of sepsis Standardization of nomenclature to advance sepsis research Critical Care Medicine 1992;20:864-874

6. Systemic Inflammatory Response Syndrome Clinical syndrome defined by the presence of two or more of the following * Fever > 100.4 or hypothermia < 96.8 * Leukocytosis > 12,000 or leukopenia <4,000 or >10%bands *Tachycardia >90 beats per minute *Tachypnea RR>20 breaths per minute

7. SIRS Criteria

8. Causes of SIRS Sepsis Severe Sepsis Septic Shock Pancreatitis Burns Trauma Other

10. Sepsis Definition: SIRS due to a suspected infection

11. Bacteremia Definition: Laboratory finding of viable bacteria in the blood Positive blood culture Blood Stream Infection (BSI) Contaminant

12. Septicemia Out dated ambiguous term In past used to imply sepsis or bacteremia Generally used to indicate sepsis with BSI

13. Severe Sepsis Definition: Sepsis with acute organ dysfunction or multiple organ dysfunction

14. Organ dysfunction Acute renal failure Acute respiratory failure Disseminated intravascular coagulopathy Encephalopathy Hepatic failure Septic shock

15. Septic Shock Definition: severe sepsis with hypotension (systolic blood pressure < 90 mmHg) unresponsive to fluids

16. Sepsis Complex medical syndrome Difficult to define, diagnosis and treat Caused by the bodies response to infection

17. Physicians confused too! Majority agree leading cause of mortality in ICU Only 22% use the concensus criteria when defining sepsis Only 17% agree on the definition of sepsis

18. Consensus Conference 2002 International panel of experts Reviewed state of knowledge of sepsis No change in definitions

19. Epidemiology Over 18 million cases of severe sepsis worldwide each year 750,000 cases of sepsis a year in the United States Growing number of cases � 1.5% annually Cost: more than $17.4 billion

20. Mortality 215,000 death in U.S. each year Kills 1,400 people worldwide every day Severe sepsis 25-30% mortality Septic Shock 40-70% mortality

21. Personal Impact Patient: often long hospitalizations Family: care after hospital Personal cost: disability, suffering, psychological affect Survivors decrease quality of life

22. Clinical Evaluation History: Possible source of infection Risk factors Fevers or shaking chills Altered mental status

23. Physical Exam May suggest source of infection Central lines Abdominal Exam Skin Exam May be unrevealing

24. Work up Lab Blood culture CBC Urine others Chest X- ray

25. Surviving Sepsis Campaign Developed to improve the management, diagnosis and treatment of sepsis Goal to decrease mortality Developed guidelines for management survivingsepsis.org

26. Treatment Antibiotics IV antibiotics within one hour of diagnosis Broad spectrum Reassess daily Duration 7-10 days

27. Treatment Fluid Therapy Vasopressors: increase BP Steroids Recombinant human activated protein C (rhAPC)

28. Coding Considerations Diagnosis of Sepsis challenging Ambiguous provider documentation Coding guidelines Coding guidelines can be difficultCoding guidelines can be difficult

29. Urosepsis The Problem Definition: Sepsis resulting from the decomposition of extravasated urine (from Stedman�s Medical Dictionary) Encourage physicians to remove urosepsis from their vocabulary

30. Coding SIRS Requires a minimum of two codes Code for the underlying cause or infection Code from subcategory 995.9x, systemic inflammatory response syndrome

31. Sepsis Coding definition: SIRS due to infection Requires a minimum of two codes Code for systemic infection (038.xx) Code for 995.91 SIRS due to infection without organ dysfunction

32. Sequencing Sepsis Dependent on physician documentation If present on admission and meets definition of principal diagnosis: Systemic infection first SIRS due to infectious process without organ dysfunction next Develops after admission sequence both as secondary codes

33. Severe Sepsis Definition: SIRS due to infection with organ dysfunction Requires a minimum of three codes Code for Systemic infection (e.g. 038.xx) Code for severe sepsis (995.92) Code for associated organ failure

34. Sequencing for Severe Sepsis Depends on provider documentation� If POA and meets principal diagnosis definition: Systemic infection first Severe sepsis 995.92 If develops during stay code both as secondary diagnosis

35. Septic Shock Circulatory failure associated with severe sepsis Represents a type of organ dysfunction Septic shock meets the definition of severe sepsis Follow coding and sequencing guidelines for severe sepsis Code also 785.52 septic shock

36. Septic Shock Code Systemic infection 038.xx Severe sepsis 995.92 Organ dysfunction Septic Shock 785.52

37. Sepsis with Localized Infection If reason for admission is sepsis and a localized infection, code systemic infection first If reason for admission is localized infection and sepsis develops, code localized infection first

38. Example #1 Patient admitted with pneumonia, respiratory failure and sepsis How would you sequence them?

39. Example #2 Patient admitted with pneumonia and respiratory failure. After admitted develops sepsis. How would you code this?

40. Example #3 Patient admitted with fever and weakness has sepsis from indwelling central line How would you code this?

41. Example #4 Patient presents with a fever and a painful swollen joint. Diagnosed with septic arthritis and sepsis How would you code this?

42. Summary Know the definitions Know the Coding Guidelines Know when to query

43. QUESTIONS?