Are you confused about Sepsis-3? Are you wondering when to assign a code for severe sepsis when that verbiage is not acknowledged in Sepsis-3? You aren’t alone in those thoughts and feelings. The goal of this blog is to provide you with a clearer understanding of Sepsis-3 and when to apply the correct ICD-10-CM code to documentation that is utilizing Sepsis-3 criteria.
Sepsis is a major public health concern, accounting for more than $20 billion (5.2%) of total US hospital costs in 2011. It’s not limited to the US alone, for even though the true incidence is unknown, conservative estimates indicate that sepsis is a leading cause of mortality and critical illness worldwide. Survivors often have long-term physical, psychological, and cognitive disabilities with significant health care and social implications.
For many years, SIRS criteria with an underlying infection have defined sepsis. While the limitations of the broadly applied definition have been recognized, there has not been a change in the definition in over two decades. Advancements in medicine led to the agreement that further research was needed for timely identification of susceptible patients and increased oversight surrounding care and treatment in an attempt to combat the high mortality rates of this illness.
On January 2014, a task force of 19 specialists from around the world convened to begin what can be called the most comprehensive study on sepsis to date, focusing on differentiating sepsis from uncomplicated infection, as well as updating the definitions of sepsis and septic shock to be consistent with improved understanding of the pathobiology. The following definition of sepsis emerged from this task force: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection
Sepsis-3 differentiates an infection from sepsis at the point where organ dysfunction is present. Several clinical scoring systems have historically been used to identify organ dysfunction, with SOFA (Sequential [Sepsis-Related] Organ Failure Assessment) being the simplest and more widely known. From the belief that organ dysfunction is the key indicator of sepsis, Sepsis-3 recommends the clinical indicators shift from SIRS criteria to those that depict organ dysfunction in six major organs/organ systems:
- Respiratory, via the P/F ratio
- Coagulation, via the platelet count
- Liver, via the bilirubin
- Cardiovascular, via the MAP or use of vasopressors
- Central Nervous System, via the GCS
- Renal, via the creatinine or urine output at certain levels
As in other scoring systems, SOFA utilizes a point system to denote the decline criteria for each of the six organ systems. A score total of 2 or more points above the patient’s baseline yield a positive indicator of organ dysfunction. The baseline SOFA score is assumed to be zero unless the patient is known to have preexisting organ dysfunction before the onset of infection.
Knowing the task force definition of sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection” and identification of SOFA as the organ dysfunction indicator, applying the FY17 Official Guidelines of Coding and Reporting to ICD-10-CM code assignment of sepsis and severe sepsis can be examined.
When there is documentation of sepsis and an organ dysfunction, official guidelines convention I.A.15 clarifies the relationship between conditions linked in the classification. According to I.A.15, “…The classification presumes a causal relationship between the two conditions linked by these terms (“with”, “associated with” and “due to”) in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.” The FY17 Alphabetic Index for sepsis reveals the following:
Sepsis (generalized) (unspecified organism) A41.9
organ dysfunction (acute) (multiple) R65.20
with septic shock R65.21
adrenal hemorrhage syndrome (meningococcal) A39.1
The above entry as seen in the Alphabetic Index meets the criteria for a causal relationship as defined in the Official Guidelines for Coding and Reporting based on the last sentence in I.A.15, “The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.”
A code for severe sepsis is assigned when the documentation satisfies the guidelines in at least one of the following in the official guidelines:
- I.C.1.d.1.a.iii Sepsis with organ dysfunction, then I.C.1.d.1.b Severe sepsis – when there is documentation of sepsis and an organ dysfunction
- I.C.1.d.1.b Severe sepsis – when the documentation states severe sepsis
- I.C.1.d.2.a Septic shock – identified as a type of organ dysfunction
A code assignment of sepsis (documented) when there is no documentation of organ dysfunction or any clinical indicators to necessitate a query for organ dysfunction is where choices will need to be decided within each facility. It is out of scope for this blog to suggest one decision over another; however, the following findings should be noted and validated:
- During a quick internet search, one can locate dozens of sepsis definitions, with several credible references such as Up-to-Date, Mayo Clinic, and CDC, including the words “life-threatening” in the definition.
- A 2010 lay definition of sepsis published by the Global Sepsis Alliance (GSA) that was often noted during the search and identified as being utilized throughout the world is, “Sepsis is a life-threatening condition that arises when the body’s response to infection injures its own tissues.”
Upon considering this information, documentation of sepsis without a notation or clinical indicator of organ dysfunction should be a clue to pause and consider whether the clinical presentation and course of treatment for the patient truly signifies what is well established clinically and supported by research – that sepsis is a life-threatening infection and leading cause of mortality and critical illness worldwide.
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP
Director of Education, MedPartners
ICD-10-CM Expert for Hospitals: The Complete Official Code Set. 2017. Optum360
ICD-10-CM Official Guidelines for Coding and Reporting. 2017. Optum360
Singer, M., Deutschman, C.S. February 23, 2016. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287. Retrieved April 14, 2016 from http://jama.jamanetwork.com/article.aspx?articleid=2492881