Part 3: Sepsis Series | Severe Sepsis Documentation and Reporting

Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

In Part 2, we focused on sepsis sequencing. In Part 3, we are going to focus on documentation needed to report the diagnosis of severe sepsis.

What is Severe Sepsis?

Severe sepsis occurs when sepsis progresses and signs of organ dysfunction/failure develop. One site stated that approximately 30% of patients with severe sepsis do not survive. Patients may develop one organ dysfunction/failure, multi-system organ failure and/or septic shock. Septic shock is severe cardiovascular dysfunction with extremely low blood pressure and hypoperfusion that does not respond to intravenous fluids. If severe sepsis is not documented correctly in the medical record, it is very difficult for coders to know how to report. A physician query may be necessary to clarify that the organ dysfunction in the record is related to the sepsis, if not documented clearly.

Cryptic septic shock is another type of shock being documented. These patients have severe lactic acidosis (4.0 mM/L or greater) and clinical signs of shock. The blood pressure may be normal in patients with cryptic septic shock. ALL patients should have a serum lactate measured that present with signs of sepsis. This elevated value may alert the physician of cryptic shock.

What Documentation is Needed to Report Severe Sepsis?

For coders, if the physician has documented severe sepsis, linked an acute organ dysfunction/failure to sepsis or the ICD-10-CM Index to Diseases directs the coder to the code for severe sepsis, it may be coded.

There are two codes for severe sepsis in ICD-10-CM that are reported in addition to the code for sepsis and any organ dysfunction/failure codes

• R65.20—Severe sepsis without septic shock
• R65.21—Severe sepsis with septic shock

Neither of these two codes are acceptable as the PDX. The ICD-10-CM Index does have instructional notes to code first the underlying infection. There are also instructional notes to use additional code to identify specific organ dysfunction. There are several organ dysfunctions listed it the ICD-10-CM Index, but this list is not an exhaustive list. A query may be necessary to clarify if the documentation is describing organ dysfunction or if the organ dysfunction is related to the diagnosis of sepsis.

Examples:

• Patient presents with altered mental status from the nursing home. She is noted in the ED to have fever, tachycardia, hypotension, elevated lactic acid, and O2 sat of 76% or room air. The patient was intubated and placed on mechanical ventilation. Labs were drawn and patient had chest x-ray that showed pneumonia in both lungs. She was admitted with the diagnosis of pneumonia with acute respiratory failure and sepsis. She was worked up and found to also have an indwelling Foley catheter that appeared to have been in place for a long time. This was removed and cultured. The labs came back to show that the patient had E. coli on the catheter tip as well as E. coli in the urine specimen that had been sent to the lab. IV antibiotics were adjusted to cover the urinary tract infection. The patient required vasopressors for hypotension that didn’t respond to intravenous fluids. Despite the IV antibiotics, fluids and IV vasopressors the patient expired. The final diagnoses were: 1. Bilateral pneumonia, most likely due to aspiration pneumonia; 2. E. coli urinary tract infection due to indwelling Foley; 3. Acute respiratory failure due to pneumonia; 4. E coli sepsis due to both aspiration pneumonia and urinary tract infection with septic shock. In this case, the PDX would be reported as A41.51 (Sepsis due to E. coli). SDX codes T83.511A (Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter), J69.0 (Pneumonitis due to inhalation of food and vomit), R65.21 (Severe sepsis with septic shock), J96.00 (Acute respiratory failure, unspecified whether with hypoxia or hypercapnia) and N39.0 (Urinary tract infection, site not specified). There were actually two possible selections for PDX. Sepsis is documented to be due to both aspiration pneumonia and UTI secondary to indwelling Foley catheter. Treatment seems to be equal with IV antibiotics, fluids and vasopressors. In this case, we went with A41.51 (Sepsis due to E. coli) as the PDX since it was one of the possible choices and it is the most resource intense DRG. Rarely will there be more than one diagnosis that meets the definition of PDX, but when there is, without further sequencing direction, either may be sequenced first.
• Patient presents from nursing home where he was found unresponsive with high fever and tachycardia of 122. After admission, the lab work did show that the patient had WBC of 26,000 and chest x-ray showed pneumonia. At the nursing home, the patient is known to be very alert on most days. IV antibiotics were started and the patient rapidly began to improve and by day 4 the altered mental status had cleared, lungs sounded much better and WBC had improved to 10,000. During the workup, the patient was found to have encephalopathy due to sepsis. Patient’s mental status was at baseline on day 5 and the patient was discharged back to the nursing home. Final diagnoses for this patient were 1. Sepsis on admission, due to pneumonia; 2. Pneumonia; 3. Encephalopathy due to sepsis and pneumonia; and 4. Fever and WBC due to sepsis. In this case, A41.9 (Sepsis, unspecified organism) would be reported as the PDX. J18.9 (Pneumonia, unspecified organism), G93.41 (Metabolic encephalopathy) and R65.20 (Severe sepsis without septic shock) would be reported as additional SDX codes. No codes were assigned for the symptoms of fever and elevated WBC since these were documented as due to sepsis. Since these are common symptoms/clinical indicators in patients with sepsis, no additional code is needed. Severe sepsis was also coded (R65.20) since the patient did have documented septic encephalopathy. Encephalopathy is listed as one of the organ dysfunctions in the instructional notes within ICD-10-CM at R65.-.

Take-Away Points:

• Severe sepsis is associated with at least one acute organ dysfunction/failure
• There are two codes for severe sepsis which indicate whether septic shock is present or not
• Approximately 30% of people diagnosed with severe sepsis will expire
• Organ dysfunction/failure must be specifically linked to the diagnosis of sepsis
• If the physician documents “severe sepsis” it is to be coded
• If the ICD-10-CM leads to coder to severe sepsis it should be coded
• The list of organ failures/dysfunctions listed in the ICD-10-CM index at R65.21 is not an exhaustive list
• The “with” guideline in the OCG (Section 1.A.15) does not apply to sepsis and organ dysfunction (the link must be made by the physician)
• When multiple conditions are responsible for the diagnosis of sepsis and the Alphabetic Index, Tabular List or other Chapter specific guideline are not present, either of the conditions may be sequenced first.

Be on the lookout for Part 4 of this series on sepsis. In Part 4 we will discuss clinical indicators needed to report the diagnosis of sepsis as well as when to query the physician for support of the diagnosis.

References
cancertherapyadvisor.com/home/decision-support-in-medicine/critical-care-medicine/severe-sepsis-and-septic-shock/
sepsis.org/sepsis-basics/what-is-sepsis/
accessmedicine.mhmedical.com/content.aspx?bookid=1340&sectionid=80033910
merckmanuals.com/professional/critical-care-medicine/sepsis-and-septic-shock/sepsis-and-septic-shock
ICD-10-CM Official Guidelines for Coding and Reporting FY 2020
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2019: Page 17
Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Page 98-100
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2016: Page 14
Coding Clinic for ICD-10-CM/PCS, Second Quarter 2017: Page 8-9

Happy Coding!

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.