Sepsis: Understanding the Confusion VHIMA Annual Convention

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Sepsis Understanding the ConfusionVHIMA Annual
Convention

• April 24, 2008
• Donna Stickley, MD, FACEP

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Objectives

• Understand the terminology
• Epidemiology
• Diagnosis and Treatment
• Coding Considerations

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Definitions Key to Understanding

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Escape Key

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Consensus Conference 1991

• Consistent definition for sepsis
• Tools for improving detection of sepsis
• Standardization of nomenclature to advance sepsis
  research
• Critical Care Medicine 199220864-874

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Systemic Inflammatory Response Syndrome

• Clinical syndrome defined by the presence of two
  or more of the following
• Fever gt 100.4 or hypothermia lt 96.8
• Leukocytosis gt 12,000 or
  leukopenia lt4,000 or gt10bands
• Tachycardia gt90 beats per minute
• Tachypnea RRgt20 breaths per minute

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SIRS Criteria
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Causes of SIRS

• Sepsis
• Severe Sepsis
• Septic Shock
• Pancreatitis
• Burns
• Trauma
• Other

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SIRS Continuum
PANCREATITIS
INFECTION
SIRS
BURNS
SEPSIS
SEVRE SEPSIS
SEPTIC SHOCK
TRAUMA
OTHER
Bone at al. Chest 1992 101 1644
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Sepsis

• Definition SIRS due to a suspected infection

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Bacteremia

• Definition Laboratory finding of viable bacteria
  in the blood
• Positive blood culture
• Blood Stream Infection (BSI)
• Contaminant

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Septicemia

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

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Severe Sepsis

• Definition Sepsis with acute organ dysfunction
  or multiple organ dysfunction

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Organ dysfunction

• Acute renal failure
• Acute respiratory failure
• Disseminated intravascular coagulopathy
• Encephalopathy
• Hepatic failure
• Septic shock

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Septic Shock

• Definition severe sepsis with hypotension
  (systolic blood pressure lt 90 mmHg) unresponsive
  to fluids

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Sepsis

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

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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

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Consensus Conference 2002

• International panel of experts
• Reviewed state of knowledge of sepsis
• No change in definitions

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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

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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

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Personal Impact

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

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Clinical Evaluation

• History
• Possible source of infection
• Risk factors
• Fevers or shaking chills
• Altered mental status

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Physical Exam

• May suggest source of infection
• Central lines
• Abdominal Exam
• Skin Exam
• May be unrevealing

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Work up

• Lab
• Blood culture
• CBC
• Urine
• others
• Chest X- ray

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Surviving Sepsis Campaign

• Developed to improve the management, diagnosis
  and treatment of sepsis
• Goal to decrease mortality
• Developed guidelines for management
• survivingsepsis.org

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Treatment

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

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Treatment

• Fluid Therapy
• Vasopressors increase BP
• Steroids
• Recombinant human activated protein C (rhAPC)

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Coding Considerations

• Diagnosis of Sepsis challenging
• Ambiguous provider documentation
• Coding guidelines

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Urosepsis

• The Problem
• Definition Sepsis resulting from the
  decomposition of extravasated urine (from
  Stedmans Medical Dictionary)
• Encourage physicians to remove urosepsis from
  their vocabulary

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Coding SIRS

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

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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

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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

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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

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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

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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

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Septic Shock

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

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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

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Example 1

• Patient admitted with pneumonia, respiratory
  failure and sepsis
• How would you sequence them?

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Example 2

• Patient admitted with pneumonia and respiratory
  failure. After admitted develops sepsis.
• How would you code this?

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Example 3

• Patient admitted with fever and weakness has
  sepsis from indwelling central line
• How would you code this?

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Example 4

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

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Summary

• Know the definitions
• Know the Coding Guidelines
• Know when to query

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QUESTIONS?