It’s September so that means it’s the beginning of Fall AND it’s Sepsis Awareness Month.  Who would have thought we needed a month dedicated to this topic? But we do!  Over the past 20 or so years the topic of Sepsis, Septicemia, Septic Shock and alike has flooded healthcare research, conferences, and medical literature. Certainly, for HIM Coding and Clinical Documentation Improvement (CDI) staff this is a topic of great interest, and we have many articles, presentations (webinars), guidelines and discussion groups on Sepsis. The “Sepsis Alliance” is promoting Sepsis awareness throughout September, go to the following site for more information: https://www.sepsis.org/get-involved/sepsis-awareness-month/

Statistics show that Sepsis causes over 11 million deaths a year worldwide.  Here in the United States, we have 1.6 million people diagnosed with Sepsis every year and approximately 250,000 die annually. Sepsis is a potentially life-threatening condition that occurs when the body’s response to an infection damages its own tissues.   So, it is understandable that there is a lot of interest in identifying, treating, and preventing Sepsis and this results in a huge volume of literature, opinion, guidelines and even payer policies.

We’ve all seen the Sepsis diagnostic criteria from 1992 that was published via the “First Consensus Statement”, that was when SIRS (Systemic Inflammatory response syndrome) was established and the diagnosis or term “Septicemia” was removed.   This particular “Sepsis 1” criteria was found to have some very real concerns with regard to the ease in meeting the criteria itself and higher incidence of Sepsis was coded across hospitals (potential over-coding). The Sepsis 1 was followed by Sepsis 2 diagnostic criteria in 2005, then came the Sepsis 3 diagnostic criteria in 2016 from “The Third International Consensus Definitions for Sepsis and Septic Shock”.  The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3) link is: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968574 

Not to be forgotten is Sequential [Sepsis-related] Organ Failure Assessment (SOFA) and quick SOFA (qSOFA) for bedside Sepsis evaluation and criteria.  All of the above definitions and guidelines helped promote the early goal-directed treatment protocol for Sepsis and enhanced awareness of the high risk of mortality for this condition.

However, during all of this there was also the “Early Goal Directed Therapy” or EGDT in 2001, the Surviving Sepsis Campaign in 2004, the 3 EGDT Randomized Controlled Trials in 2014 and the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016 which declared Sepsis a major health concern. The link to the Surviving Sepsis Campaign/Society of Critical Care Medicine guideline can be found at the following link: https://link.springer.com/content/pdf/10.1007%2Fs00134-017-4683-6.pdf  Other published information on “The Surviving Sepsis Guidelines” or the Surviving Sepsis Campaign are available at  http://www.survivingsepsis.org.

The Centers for Medicare and Medicaid Services (CMS) also was concerned with the high risk of mortality with Sepsis patients (beneficiaries) and they were a part of this diagnostic criteria mix with the release of the Sepsis Core Measure. CMS has a seven (7) page “Severe Sepsis and Septic Shock: Management Bundle (Composite Measure)”, Measure Inventory Tool, which is available at: https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=1017#:~:text=Severe%20Sepsis%20and%20Septic%20Shock%3A%20Management%20Bundle%20%28Composite,excluded%20from%20…%20%202%20more%20rows%20   Wow,  this can certainly make your head spin or at least require thorough and repeated reading to fully understand the criteria for establishing a Sepsis diagnosis as well as Severe Sepsis and Septic Shock.

Most hospital inpatient encounters with a principal diagnosis of “Sepsis” will group to MDC 18, Infectious & Parasitic Diseases, Systemic or Unspecified Sites, resulting in one of the following MS-DRGs:

DRG 862 – POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC

DRG 863 – POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC

DRG 864 – FEVER AND INFLAMMATORY CONDITIONS

DRG 865 – VIRAL ILLNESS WITH MCC

DRG 866 – VIRAL ILLNESS WITHOUT MCC

DRG 867 – OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC

DRG 868 – OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC

DRG 869 – OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC

DRG 871 – SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC

DRG 872 – SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC

The titles help identify when mechanical ventilation is also performed during the hospital encounter which greatly raises the severity of the encounter.  When there is an operative procedure performed and coded in a case with a Principal diagnosis of Sepsis, then the MS-DRGs would most likely be one of the following:

DRG 853 – INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURE WITH MCC

DRG 854 – INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURE WITH CC

DRG 855 – INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURE WITHOUT CC/MCC

DRG 856 – POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURE WITH MCC

DRG 857 – POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURE WITH CC

DRG 858 – POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURE WITHOUT CC/MCC

DRG 870 – SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS OR PERIPHERAL EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

When we find severe sepsis documented in the medical record, there will be a minimum of two ICD-10-CM codes (according to the Official Guideline I.C.1.d.1.b.). First, a code for the underlying systemic infection (i.e., sepsis) is assigned, followed by a code for severe sepsis (R65.2-). If organ dysfunction other than septic shock is present, add the codes for the specific organ dysfunction (i.e., Respiratory failure, liver failure, renal failure).  AHA Coding Clinic® (Vol. 3, No. 3, p. 8) advises using ICD-10-CM code A41.89 Other specified sepsis for sepsis due to viral infections even though this code is found in Chapter 1 Other Bacterial Diseases section (A30-A49). Since theCOVID-19  Public Health Emergency (PHE) we have seen more Sepsis encounters which for clinical coding will require a strong knowledge of the Official Guidelines, information published in the AHA ICD-10-CM/PCS Coding Clinic and pathophysiology (disease process).  Remember, when sepsis occurs with COVID-19, follow guidelines I.C.1.d.1-4 for sequencing.

I recently was involved in a focused MS-DRG audit and the MS-DRG 871 SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC was included.  When performing the documentation and coding review and validation, the auditor made it known that they were using the Sepsis 2 clinical criteria and this was found to be very helpful to the HIM Coding and CDI staff.  In addition, the Office of Inspector General (OIG) MS-DRG report from February 2021 titled: Trend Toward More Expensive Inpatient Hospital Stays in Medicare Emerged Before COVID-19 and Warrants Further Scrutiny. which includes MS-DRG 871 with a length of stay below the GMLOS is stated to be an at risk- DRG and this report provided a guide for the selection of encounters for this focused audit.  This particular OIG report indicates that approximately 50% of Medicare payments for inpatient hospital stays were based on the highest severity MS-DRG (https://oig.hhs.gov/oei/reports/OEI-02-18-00380.pdf) Thus, for this MS-DRG audit the Official Guidelines, AHA Coding Clinic and the Sepsis 2 criteria were utilized and, it was found that the documented clinical indicators didn’t correlate to a diagnosis of Sepsis in several encounters. In addition, although “Sepsis” was documented on admission, it was found NOT to meet the definition of principal diagnosis resulted in an overpayment and even underpayments in several encounters.  The third audit finding was regarding the sequencing of Sepsis as principal diagnosis when compared to the circumstances of admission.  These findings speak to the educational aspects of having a coding audit performed which has the benefit of continuous learning which is part of the clinical coding process.

Some things that would be important to think about and discuss with HIM Coding and CDI about Sepsis includes the following:

  • Which sepsis “Criteria” is being used at your facility and with your Medical Staff?
  • How many inpatient MS-DRGs payer denials have you had in the past 24 months with the principal diagnosis of Sepsis?
  • What does your Sepsis diagnosis frequency in a given year (# of Inpatient encounters)?  And how does this compare to the PEPPER?
  • When the inpatient encounter is at least one day less than the Geometric length of stay, that encounter may warrant a second look before finalizing the coding;
  • There are two components to the selection of the principal diagnosis; the circumstances of admission and the condition found after study to be chiefly responsible for admission to the hospital;
  • When and why to query the provider regarding a documented diagnosis of “Sepsis”?
  • How can HIM Coding and CDI staff help to improve the documentation of and surrounding “Sepsis”?

Always review/read through the medical record documentation and try to ascertain if there is missing, conflicting and/or contrasting information.  We should of course also always be looking for under-documentation of Sepsis but also if this condition is over-documented. It’s important from a compliance perspective to identify both over and under payments, as these findings can drive the accuracy of the clinical data and reimbursement.  It’s Sepsis awareness month so now is the  time to conduct a few focused MS-DRG audits and in particular look at some encounters for MS-DRGs with a principal diagnosis or as a secondary diagnosis of “Sepsis”.

Reimbursement Management Consultants (RMC) can provide assistance with medical coding support, auditing, education, compliance consulting, and HCC/risk adjustment services. RMC is a woman-owned, US-based and operated company which specializes in a variety of medical coding and auditing services. Contact us here.

Written by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer