Part 1: Sepsis Series | What is Sepsis?
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
This is part 1 in a series focused on coding of sepsis. Sepsis remains one of the most common diagnoses reported, but is also one of the most common found in denials. In this series, we will learn what sepsis is or causes of sepsis, how to sequence the diagnosis in ICD-10-CM, what are the clinical indicators for sepsis, is a query necessary before reporting the diagnosis of sepsis, and how to prevent denials on sepsis records.
What is Sepsis?
Sepsis is a common diagnosis in the United States and it is estimated that between one and three million Americans are diagnosed each year with this condition. Of these, about 22 percent will die on average.
Sepsis is defined as a very serious medical condition and is the overwhelming response to infection. Sepsis progresses rapidly once it has begun and leads to organ damage. In the more serious cases of sepsis, one or more of the patient’s organs will fail. In the worse cases, the patient will develop septic shock, and when that occurs multiple organs will fail and the patient may find it very difficult to recover.
What Causes Sepsis?
Bacteria is the most common cause of sepsis, but it can also be due to fungus or a virus. When this occurs the patient’s blood culture will oftentimes be positive for the causative organism. However, a negative blood culture does not negate the diagnosis of sepsis. When the blood culture is negative, the physician is using other clinical findings of the patient to make the diagnosis of sepsis. The most common clinical findings that are used by physicians to make this diagnosis are:
- High fever or low temperature (usually >100.4 F (38 C) or hypothermia <96.8 (36C)
- Tachycardia (usually HR over 90)
- Confirmed or suspected localized infection
- Decreased mental status
- Tachypnea (usually respiratory rate over 20)
- Chills due to fall in body temperature
- Elevated white count (more than what is seen with just a localized infection usually less than 4,000 or greater than 12,000)
Keep in mind that there are a plethora of clinical indicators, according if Sepsis-1, Sepsis-2 or Sepsis-3 criteria are used.
The number of sepsis cases in the United States increase each year. This is felt to be due to the aging population, increase in antibiotic resistance, and more people diagnosed with conditions that create a weaker immune system. Anyone of any age can develop sepsis, but it is more prevalent in the older population.
How is Sepsis Coded?
Coding the diagnosis of sepsis is a very difficult task for coders since coders see incomplete and contradictory documentation within many of the hospital records. There are many codes in ICD-10-CM for reporting the diagnosis of sepsis depending on the organism or cause. Many times, queries are needed for clarification prior to final coding of the hospital record. We will learn more on querying for sepsis as this series progresses.
The most common sepsis code reported in the United States is A41.9 (Sepsis, unspecified organism). When this is reported, the patient’s blood culture was negative for any causative organism. We will also be looking at sequencing of the diagnosis of sepsis in Part 2 of this series. Please be on the lookout for this next part.
ICD-10-CM Official Guidelines for Coding and Reporting FY 2020
Coding Clinic for ICD-10-CM/PCS, First Quarter 2018: Page 16
Coding Clinic, Second Quarter 2000 Page: 5
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
In the previous three parts of this four-part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2021.
This is Part 2 of a 4 part series on the FY2021 ICD-10 Code and IPPS changes. In this part, the ICD-10-PCS procedure codes are presented. For FY2021 ICD-10-PCS there are 78,115 total codes (FY2020 total was 77,571); 556 new codes (734 new last year in FY2020)…
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
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Lately we have seen several cases where the endarterectomy was assigned along with the coronary artery bypass (CABG) procedure when being performed on the same vessel to facilitate the CABG. A coronary artery endarterectomy is not always performed during a CABG procedure, so when it is performed it becomes confusing as to whether to code it separately or not.
Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
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Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
In the first parts of this series we looked at definitions of AKI/ARF, causes, coding and sequencing. In Part 3, we will look at what clinical indicators would possibly be present to support the diagnosis of AKI/ARF.
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
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Coronavirus: Tips for working from home. Companies around the world have told their employees to stay home and work remotely. Whether you’re a new to this concept or a work from home veteran, here’s some tips to staying productive from our #HIAfamily.
This is the final part of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we provide an actual example of an effective communication response to CDI.
This is part two of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we discuss mismatches and how to best go about resolving them. In part three we will provide a case example of best practice interaction.
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