Query Tip: When to Query for Sepsis

SIRS criteria indicate a clinical response to a non-specific insult, either infectious or noninfectious in origin, but not necessarily a systemic, life-threatening infection such as sepsis.  SIRS is defined as 2 or more of the following:

• Fever >38◦C or < 36◦C
• Heart rate >90 beats per minute
• Respiratory rate >20 breaths per minute or PaCO2 <32 mm Hg
• Abnormal white blood cell count (>12,000/mm3 or <4,000/ mm3 or >10% bands)

A query for sepsis based only on SIRS criteria being met would not be appropriate. These indicators could be explained by another condition, i.e. pneumonia, cellulitis, pancreatitis. If the patient looks well or nontoxic, he/she probably does not have sepsis.  There should be a constellation of signs/symptoms related to several organ functions, in addition to the SIRS criteria. In lay terms, sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs. There are many clinical criteria in addition to the SIRS criteria that can be used in support of a sepsis query. Some of these include:

• Hypotension
• Elevated lactic acid
• Metabolic acidosis
• Altered mental status/confusion
• Lethargy/weakness
• Multi-organ failure
• Coagulopathy
• Positive blood cultures

There has been a great deal of variability in clinical criteria recognized as sepsis, making it more difficult for coders to know when a query for the diagnosis or clinical validity may be appropriate. A task force of leading sepsis experts introduced a new definition for sepsis and septic shock in 2016 known as Sepsis-3.  This definition gives more weight to organ dysfunction and less to SIRS criteria (Sepsis-2 definition) in identifying potential sepsis cases.  Coders may run into a situation where a payor or auditor may be following the clinical criteria set forth in this new definition, while the physician may still be using the previous definition.  Even ICD-10-CM sepsis codes are based on the older definition at the present time.  This can lead to case denials unless the physician documentation fully describes the severity of the patient’s condition and supports the clinical diagnosis of sepsis. Coders will have to take this into consideration when trying to decide if a query is appropriate. If the documentation is not adequate, a query would not be recommended.

For more information about Sepsis-3 and how it may impact coding and querying for sepsis, see:

esicm.org/article-review-sepsis-3-depascale/
icd10monitor.com/payers-and-clinicians-should-use-clinically-accepted-criteria-when-diagnosing-sepsis
icd10monitor.com/sirs-sepsis-and-rule-no-1

The information contained in this query 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.