Sepsis

1
Sepsis Impact of Coding upon Metrics
2
Sepsis Impact of Coding upon Metrics

• Paul Evans, RHIA, CCS, CCS-P, CCDS
• Manager, CDI
• Sutter West Bay
• San Francisco, CA
• (evanspx_at_sutterhealth.org)

3
Agenda

• WHY Care About Coding?
• WHAT is Required for Accurate Data?
• HOW is Sepsis Coded?
• Impact of Key Terms Upon Data (ROM)
• Documentation Tips for Sepsis

4
Why Care About Coding?

• Accuracy of severity and predicted mortality
  factors are adjusted for risk using coding
• Public Reporting

5
Data Trends

• Financial
• 3rd parties use coded data for reimbursement,
  audits and compliance
• Consumers
• Healthgrades Leapfrog State Organizations
  CMS
• Pay for Performance
• RAC, Value-Based Purchasing, Never Events

6
Why Does Data Matter? (Hospital and physician
profiling data is available to the public)
7
(No Transcript)
8
Public Websites on Outcomes Coding Used to
Report Outcomes
9
Increased Physician Scrutiny

• Without all factoring conditions documented,
  profiles will inappropriately reflect higher than
  expected mortality
• Complete documentation, reflective of the true
  severity of your patients, helps justify outcomes
• Profiles are used for both commercial and public
  use - Future reimbursement methods will likely
  incorporate profiles in the formula (pay for
  performance)

10
Formulas for Sepsis MD Facility Scores

• Combined mortality for Severe Sepsis (ICD-9
  995.92) and Septic Shock (785.52)
• (Number of expired severe sepsis patients
  Number of expired septic shock patients) /
  (Number of severe sepsis cases Number of septic
  shock cases).
• Ratio of Observed to Expected Mortality for
  Septicemia Disseminated Infections (APR-DRG
  720)
• Number of observed expired septicemia
  disseminated infection patients / Number of
  expected expired septicemia disseminated
  infection patients. IMPACTED BY Coding of
  Septic Patients

11
Sepsis Coding Formula

• Note the codes for Severe Sepsis and Septic Shock
  must be applied in order for accurate reporting
  of outcomes
• The coding is driven by very explicit clinical
  documentation of discharges noted at the time of
  discharge
• It is possible that Severe Sepsis with Shock will
  be treated, and the Bundles will be completed,
  but cases will not be in the study due to coding
  issues?

12
Problematic Terms

• Urosepsis, Bacteremia, Pneumonia Hypotension
• Severe Sepsis or Septic
  Shock!
• Severe Sepsis with Multi-Organ Failure
  Explicitly document the specific organ failure

13
The AHRQ Quality Indicators and the APR-DRGs

• The APR DRGs - used by Agency for Healthcare
  Research and Quality (AHRQ) for risk adjustment
  to the Inpatient Quality Indicators (IQI)
• The IQI - indicators of inpatient mortality for
  selected procedures and conditions.

14
APR-DRG Gold Standard for Risk-Adjusted
Outcomes Data

• The determination of the severity of illness
  and risk of mortality is disease-specific
  (Different ROM for patient admitted with Acute
  Exacerbation of Asthma, Simple or Complex PNA,
  CVA, Sepsis, so forth)

15
APR-DRG Gold Standard for Risk-Adjusted
Outcomes Data

• In APR DRGs, high severity of illness or risk of
  mortality are primarily determined by the
  interaction of multiple diseases
• Patients with multiple comorbid conditions
  involving multiple organ systems represent
  difficult-to-treat patients who tend to have poor
  outcomes

16
Uses of APR-DRG

• To quantify demographic and clinical risk
  factors.
• Comparisons between disparate populations or
  groups.
• Clinical outcomes
• Mortality
• Complications
• Utilization measures
• Length of Stay
• Cost

17
APR-DRG Structure

• Set of patient groups (APR-DRGs) that include
  adjustments for Severity of Illness (SOI) and
  Risk of Mortality (ROM)
• The groups are designed to describe the complete
  cross-section of patients seen in acute care
  hospitals
• Four subclasses (Grade 1 -4) for both SOI ROM
• Clinical model that has been extensively refined
  with historical data from all payers and the
  logic is open to users.

18
System Generates SOI/ROM for All Acute Admissions

• Four Severity of Illness Subclasses
• Minor
• Moderate
• Major
• Extreme
• Physiologic decompensation or
• organ system loss of function

• Four Risk of Mortality Subclasses
• Minor
• Moderate
• Major
• Extreme
• Likelihood of dying

19
APR Examples 65 y/o admitted with Severe Sepsis
Note Impact of Types of ARF
Option 1 Option 2 Option 3 Option 4 Option 5
Severe Sepsis Severe Sepsis Severe Sepsis Severe Sepsis Severe Sepsis
SDx None SDx ATN SDx Acute Cortical Necrosis SDx Acute Medullary Necrosis SDx ARF, Not Specified
SOI 1 SOI 3 SOI 3 SOI 3 SOI 2
ROM 1 ROM 3 ROM 2 ROM 2 ROM 2
20
Note Impact of Other Organ Failure
Option 1 Option 2 Option 3 Option 4 Option 5
Severe Sepsis Severe Sepsis Severe Sepsis Severe Sepsis Severe Sepsis
SDx Critical Illness Myopathy SDx DIC SDx Encephalopathy SDx Shock Liver SDx Septic Shock
SOI 3 SOI 3 SOI 2 SOI 3 SOI 2
ROM 2 ROM 3 ROM 2 ROM 3 ROM 3
21
Impact of Multiple Organ Failures on SOI/ROM
Option 1 Option 2 Option 3 Option 4
Severe Sepsis Severe Sepsis Severe Sepsis Severe Sepsis
SDx UTI SDx UTI (ADD) Septic Shock SDx UTI Septic Shock (ADD) Acute Renal Failure SDx UTI Septic Shock Acute Renal Failure (ADD DIC)
SOI 1 SOI 2 SOI 3 SOI 4
ROM 2 ROM 3 ROM 4 ROM 4
22
Lower to Greater SOI

• Clinically Significant but Low SOI

• Greater SOI Captured

• Severe Hypoxia (SS)
• Urosepsis
• Uncontrolled NIDDM
• Severe COPD on continuous O2
• Community Acquired Pneumonia and dysphasia,
  s/p CVA.
• Serum Na of 145 mEq/L

• Early or mild Acute Respiratory Failure
• UTI with Sepsis
• Type 2 DM with Hyperosmolarity, uncontrolled.
• Chronic Respiratory Failure
• Possible Aspiration Pneumonia -Community Acquired
• Hypernatremia

23
Examples Documenting Consequences of Sepsis

• Acute Kidney Failure - not insufficiency
• Acute Respiratory Failure not hypoxia
• Critical Illness Myopathy not weakness
• DIC not coagulopathy
• Encephalopathy not AMS
• Acute Hepatic Failure Not Elevated Liver
  Enzymes
• Septic Shock not hypotension
• State ALL manifestations of Sepsis in the
  Discharge Diagnosis!

24
Importance of Reliable Documentation Best
Place Discharge Summary

• Discharge summary documents all significant
  conditions
• Discharge summary must be consistent with
  documentation in the body of the record. If not,
  query the physician

25
Discharge Documentation - Example

• The summary should clarify if conditions were
  present on admission and have resolved, are still
  to be ruled out, or were in fact ruled out.
• Admission note Sepsis with Septic Shock
  secondary to Pneumonia.
• Progress note Sepsis, and Shock improving.
• Discharge summary Sepsis, Septic Shock and
  pneumonia, resolved

26
Coding Brief Notes

• Bacterial Sepsis and Septicemia
• In most cases, it will be a code from category
  038, Septicemia, that will be used in conjunction
  with a code from subcategory 995.9 such as the
  following
• Streptococcal sepsis If the documentation in the
  record states streptococcal sepsis, codes 038.0,
  Streptococcal septicemia, and code 995.91 should
  be used, in that sequence.
• Streptococcal septicemia If the documentation
  states streptococcal septicemia, only code 038.0
  should be assigned, however, the provider should
  be queried whether the patient has sepsis, an
  infection with SIRS

27
Coding Brief Notes

• Sepsis or severe sepsis may be present on
  admission, but the diagnosis may not be confirmed
  until sometime after admission
• If the documentation is not (crystal) clear
  whether the sepsis or severe sepsis was present
  on admission, the provider should be queried
• May have quality implications

28
Special Note Comfort Care

• Document reasons for Comfort Care
• All patients factor into the MD personal O/E
  (Outcomes) data and the facility O/E (Outcomes)
  Data

29
Query??

• A coder or other concurrent reviewer may query
  a clinician regarding Severe Sepsis if certain
  conditions are present and the condition is not
  stated (or, sepsis IS stated, but not supported
  by clinical indicators)
• AHIMA released Guidelines for Achieving a
  Compliant Query Practice, in the February 2013
  edition of the Journal of AHIMA. The document,
  created in collaboration with ACDIS volunteers
  and approved by the ACDIS Advisory Board, states
  that coding (or CDI) staff should query the
  physician if a diagnosis is not supported by
  clinical indicator(s) in the medical record

30
Query??

• The focus of external audits has expanded in
  recent years to include clinical validation
  review. The Centers for Medicare and Medicaid
  Services (CMS) has instructed coders to refer to
  the Coding Clinic guidelines and query the
  physician when clinical validation is required.
  The practitioner does not have to use the
  criteria specifically outlined by Coding Clinic,
  but reasonable support within the health record
  for the diagnosis must be present. When a
  practitioner documents a diagnosis that does not
  appear to be supported by the clinical indicators
  in the health record, it is currently advised
  that a query be generated to address the conflict
  or that the conflict be addressed through the
  facilitys escalation policy
• Source AHIMA Practice Brief Guidelines for
  Achieving a Compliant Query Practice

31
Query??

• The generation of a query should be considered
  when the health record documentation
• Is conflicting, imprecise, incomplete, illegible,
  ambiguous, or inconsistent
• Describes or is associated with clinical
  indicators without a definitive relationship to
  an underlying diagnosis
• Includes clinical indicators, diagnostic
  evaluation, and/or treatment not related to a
  specific condition or procedure
• Provides a diagnosis without underlying clinical
  validation
• Is unclear for present on admission indicator
  assignment

32
Query??

• Best Practice for Facility
• Accredited Coders/CDI Staff
• Linkage to Physician Advisors Quality Staff
• Facility formulation, to the extent possible of
  evidence-based and physician approved definitions
  for major/key conditions AMI, ARF, Sepsis,
  Septic Shock, Acute Respiratory Failure, CHF
• Define, Document, Defend using approved
  definitions
• Support Quality Measures and generate ACCURATE
  coding to support risk-adjusted outcomes data

33
Sample Study Why is O/E Not on Par?
34
Data Mining

• Ensure all expired cases with low scores (2 or
  less) are reviewed systematically by clinician
  and coder prior to final coding
• Review APR/DRG 720 for ROM/SOI Scores
• Review cases with code assignment for 995.92
  Severe Sepsis with a ROM of 2 or less
  (995.92, Severe Sepsis) implies an organ failure
  the ROM is could be greater than 2 when
  certain organ failure or combinations is/are
  reported with Severe Sepsis
• Review cases with major infections that ARE NOT
  coded to Sepsis Did these meet the SIRS
  Criteria and are not coded to Sepsis?
• Examples, patients with Pneumonia, SBP,
  Cholangitis focus on those with high charges
  and/or extended LOS (GMLOS per MS-DRG Methodology)

35
Questions?