Sepsis – Impact of Coding upon
Metrics
Sepsis – Impact of Coding upon
Metrics
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, CDI
Sutter West Bay
San Francisco, CA
(evanspx@sutterhealth.org)
Agenda
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WHY Care About Coding?
WHAT is Required for Accurate Data?
HOW is Sepsis Coded?
Impact of Key Terms Upon Data (ROM)
Documentation “Tips” for Sepsis
Why Care About Coding?
• Accuracy of severity and predicted mortality –
factors are adjusted for risk using coding
• Public Reporting
Data Trends
• Financial
– 3rd parties use coded data for reimbursement,
audits and compliance
• Consumers
– Healthgrades – Leapfrog – State Organizations –
CMS
• Pay for Performance
– RAC, Value-Based Purchasing, Never Events
Why Does Data Matter? (Hospital and physician
profiling data is available to the public)
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Public Websites on Outcomes – Coding Used
to Report Outcomes
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Increased Physician Scrutiny
• Without all factoring conditions documented,
profiles will inappropriately reflect higher than
expected mortality
• Complete documentation, reflective of the true
severity of your patients, helps justify outcomes
• Profiles are used for both commercial and public
use - Future reimbursement methods will likely
incorporate profiles in the formula (pay for
performance)
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Formulas for Sepsis = MD & Facility Scores
• Combined mortality for Severe Sepsis (ICD-9
995.92) and Septic Shock (785.52)
(Number of expired severe sepsis patients + Number
of expired septic shock patients) / (Number of severe
sepsis cases + Number of septic shock cases).
• Ratio of Observed to Expected Mortality for
Septicemia & Disseminated Infections (APR-DRG
720)
– Number of observed expired septicemia & disseminated
infection patients / Number of expected expired
septicemia & disseminated infection patients. IMPACTED
BY – Coding of Septic Patients
Sepsis Coding “Formula”
• Note the codes for Severe Sepsis and Septic
Shock must be applied in order for accurate
reporting of outcomes
• The coding is driven by very explicit clinical
documentation of discharges noted ‘at the time
of discharge’
• It is possible that Severe Sepsis with Shock will be
treated, and the Bundles will be completed, but
cases will not be in the study due to coding
issues?
Problematic Terms
• Urosepsis, Bacteremia, Pneumonia & Hypotension:
= Severe Sepsis or Septic Shock!
• Severe Sepsis with Multi-Organ Failure – Explicitly
document the specific organ failure
The AHRQ Quality Indicators and the
APR-DRGs
• The APR DRGs - used by Agency for Healthcare
Research and Quality (AHRQ) for risk adjustment to
the Inpatient Quality Indicators (IQI)
• The IQI - indicators of inpatient mortality for
selected procedures and conditions.
APR-DRG – Gold Standard for RiskAdjusted Outcomes Data
The determination of the severity of illness
and risk of mortality is disease-specific
(Different ROM for patient admitted with
Acute Exacerbation of Asthma, Simple or
Complex PNA, CVA, Sepsis, so forth)
APR-DRG – Gold Standard for RiskAdjusted Outcomes Data
• In APR DRGs, high severity of illness or risk of
mortality are primarily determined by the
interaction of multiple diseases
• Patients with multiple comorbid conditions
involving multiple organ systems represent
difficult-to-treat patients who tend to have
poor outcomes
Uses of APR-DRG
• To quantify demographic and clinical risk factors.
• Comparisons between disparate populations or groups.
• Clinical outcomes
– Mortality
– Complications
• Utilization measures
– Length of Stay
– Cost
APR-DRG – Structure
• Set of patient groups (APR-DRGs) that include
adjustments for Severity of Illness (SOI) and Risk
of Mortality (ROM)
• The groups are designed to describe the
complete cross-section of patients seen in acute
care hospitals
• Four subclasses (Grade 1 -4) for both SOI & ROM
• Clinical model that has been extensively refined
with historical data from all payers and the logic
is open to users.
System Generates SOI/ROM for All
Acute Admissions
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Four Severity of Illness Subclasses •
Four Risk of Mortality Subclasses
1.
Minor
1.
Minor
2.
Moderate
2.
Moderate
3.
Major
3.
Major
4.
Extreme
4.
Extreme
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Physiologic decompensation or
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organ system loss of function
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Likelihood of dying
APR Examples: 65 y/o admitted with Severe
Sepsis – Note Impact of Types of ARF
Option 1
Option 2
Option 3
Option 4
Option 5
Severe Sepsis
Severe Sepsis
Severe Sepsis
Severe Sepsis
Severe Sepsis
SDx: None
SDx: ATN
SDx: Acute
Cortical
Necrosis
SDx: Acute
Medullary
Necrosis
SDx: ARF, Not
Specified
SOI : 1
SOI : 3
SOI : 3
SOI : 3
SOI : 2
ROM: 1
ROM: 3
ROM: 2
ROM: 2
ROM: 2
Note Impact of Other Organ Failure
Option 1
Option 2
Option 3
Option 4
Option 5
Severe Sepsis
Severe Sepsis
Severe Sepsis
Severe Sepsis
Severe Sepsis
SDx: Critical
Illness
Myopathy
SDx: DIC
SDx:
SDx: Shock
Encephalopathy Liver
SDx: Septic
Shock
SOI : 3
SOI : 3
SOI : 2
SOI : 3
SOI : 2
ROM: 2
ROM: 3
ROM: 2
ROM: 3
ROM: 3
Impact of Multiple Organ Failures on SOI/ROM
Option 1
Option 2
Option 3
Option 4
Severe
Sepsis
Severe
Sepsis
Severe Sepsis
Severe Sepsis
SDx: UTI
SDx: UTI &
(ADD) Septic
Shock
SDx: UTI & Septic
Shock & (ADD) Acute
Renal Failure
SDx: UTI & Septic
Shock & Acute Renal
Failure (ADD DIC)
SOI : 1
SOI : 2
SOI : 3
SOI : 4
ROM: 2
ROM : 3
ROM: 4
ROM: 4
Lower to Greater SOI
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Clinically Significant but Low
SOI:
Severe Hypoxia (S&S)
Urosepsis
Uncontrolled NIDDM
Severe COPD on continuous
O2
Community Acquired
Pneumonia and dysphasia,
s/p CVA.
Serum Na of 145 mEq/L
Greater SOI Captured:
• Early or mild Acute Respiratory
Failure
• UTI with Sepsis
• Type 2 DM with Hyperosmolarity,
uncontrolled.
• Chronic Respiratory Failure
• Possible Aspiration Pneumonia Community Acquired
• Hypernatremia
Examples: Documenting Consequences of Sepsis
• Acute Kidney Failure - not insufficiency
• Acute Respiratory Failure – not hypoxia
• Critical Illness Myopathy – not weakness
• DIC – not coagulopathy
• Encephalopathy – not AMS
• Acute Hepatic Failure – Not Elevated Liver Enzymes
• Septic Shock – not hypotension
State ALL manifestations of Sepsis in the Discharge Diagnosis!
Importance of Reliable Documentation:
Best Place = Discharge Summary
• Discharge summary documents all significant conditions
• Discharge summary must be consistent with documentation in the body of
the record. If not, query the physician
Discharge Documentation Example
The summary should clarify if conditions were
present on admission and have resolved, are
still to be ruled out, or were in fact ruled out.
– Admission note: “Sepsis with Septic Shock
secondary to Pneumonia.”
– Progress note: “Sepsis, and Shock improving.”
– Discharge summary: “Sepsis, Septic Shock and
pneumonia, resolved”
Coding – Brief Notes
• Bacterial Sepsis and Septicemia
– In most cases, it will be a code from category 038, Septicemia, that will
be used in conjunction with a code from subcategory 995.9 such as the
following:
• Streptococcal sepsis If the documentation in the record states
streptococcal sepsis, codes 038.0, Streptococcal septicemia, and code
995.91 should be used, in that sequence.
• Streptococcal septicemia If the documentation states streptococcal
septicemia, only code 038.0 should be assigned, however, the provider
should be queried whether the patient has sepsis, an infection with SIRS
Coding – Brief Notes
• Sepsis or severe sepsis may be present on
admission, but the diagnosis may not be
confirmed until sometime after admission
• If the documentation is not (crystal) clear
whether the sepsis or severe sepsis was
present on admission, the provider should be
queried
• May have quality implications
Special Note – Comfort Care
• Document reasons for “Comfort Care”
• All patients factor into the MD personal O/E (Outcomes) data
and the facility O/E (Outcomes) Data
Query??
• A coder or other concurrent reviewer may ‘query’ a
clinician regarding Severe Sepsis if certain conditions
are present and the condition is not stated (or, sepsis
IS stated, but not ‘supported’ by clinical indicators)
• AHIMA released “Guidelines for Achieving a Compliant
Query Practice,” in the February 2013 edition of the
Journal of AHIMA. The document, created in
collaboration with ACDIS volunteers and approved by
the ACDIS Advisory Board, states that coding (or CDI)
staff should query the physician if a diagnosis is not
supported by clinical indicator(s) in the medical record
Query??
• “The focus of external audits has expanded in recent years to
include clinical validation review. The Centers for Medicare and
Medicaid Services (CMS) has instructed coders to ‘refer to the
Coding Clinic guidelines and query the physician when clinical
validation is required.’ The practitioner does not have to use the
criteria specifically outlined by Coding Clinic, but reasonable
support within the health record for the diagnosis must be present.
When a practitioner documents a diagnosis that does not appear to
be supported by the clinical indicators in the health record, it is
currently advised that a query be generated to address the conflict
or that the conflict be addressed through the facility’s escalation
policy”
• Source: AHIMA Practice Brief Guidelines for Achieving a Compliant
Query Practice
Query??
The generation of a query should be considered when the
health record documentation:
• Is conflicting, imprecise, incomplete, illegible, ambiguous,
or inconsistent
• Describes or is associated with clinical indicators without a
definitive relationship to an underlying diagnosis
• Includes clinical indicators, diagnostic evaluation, and/or
treatment not related to a specific condition or procedure
• Provides a diagnosis without underlying clinical validation
• Is unclear for present on admission indicator assignment
Query??
• Best Practice for Facility
– Accredited Coders/CDI Staff
– Linkage to Physician Advisors & Quality Staff
– Facility formulation, to the ‘extent possible’ of
evidence-based and physician approved definitions for
major/key conditions – AMI, ARF, Sepsis, Septic
Shock, Acute Respiratory Failure, CHF
– Define, Document, Defend using approved definitions
– Support Quality Measures and generate ACCURATE
coding to support risk-adjusted outcomes data
Sample Study – Why is O/E Not on Par?
Data Mining
• Ensure all expired cases with low scores (2 or less) are reviewed
systematically by clinician and coder prior to final coding
• Review APR/DRG 720 for ROM/SOI Scores
– Review cases with code assignment for 995.92 : Severe Sepsis – with a
ROM of ‘2’ or less (995.92, Severe Sepsis) implies an organ failure –
the ROM is could be greater than ‘2’ when certain organ failure or
combinations is/are reported with Severe Sepsis
• Review cases with major infections that ARE NOT coded to Sepsis – Did
these meet the SIRS Criteria and are not coded to Sepsis?
– Examples, patients with Pneumonia, SBP, Cholangitis – focus on those
with high charges and/or extended LOS (GMLOS per MS-DRG
Methodology)
Questions?