Sepsis (Part 2)
Several RAC denials have shown
that there may be confusion regarding
the sequencing of sepsis with other
conditions. The following is suggested
advice to follow when coding or
querying for these types of records:
Admitted with Sepsis, Pneumonia, and Respiratory
Failure
Issue 2 August/September 2011
Content
Sepsis (Part 2)
New RAC Issues
Current RAC Audit Request
If the patient is admitted with both pneumonia and
sepsis, sequence sepsis as the principal diagnosis (AHA
Coding Clinic 2003, fourth quarter, pages 79-81). If the
patient is admitted with both pneumonia and respiratory
failure, sequence respiratory failure as the principal
diagnosis (AHA Coding Clinic 2003, second quarter,
pages 21-22).
If the patient is admitted with respiratory failure due to
or associated with an acute non-respiratory condition
(such as sepsis), then the acute non-respiratory condition
(i.e. Sepsis) is sequenced as the principal diagnosis. And
since respiratory failure is an organ dysfunction of
SIRS/sepsis, it should be listed as a secondary diagnosis
(AHA Coding Clinic 1991, second quarter, pages 3-5).
Following this logic, if a patient is admitted with all
three - sepsis, pneumonia, and respiratory failure - then
the sepsis will more than likely be sequenced as the
principal diagnosis as it is the acute condition causing
the respiratory failure. However, look closely at the
record, if the documentation specifically supports that
the respiratory failure was caused by another respiratory
condition (not caused by the sepsis) then it may be
appropriate to sequence respiratory failure as the
principal diagnosis.
Continued on page 2
end with the suffix “-itis” that many assume to be
infections, such as cellulitis, diverticulitis, orchitis,
cholangitis, and the like, are not infections unless the
physician explicitly states that these are infections.
(AHA Coding Clinic 2010, first quarter, p. 10)
Sepsis/Severe Sepsis/SIRS with a Localized Infection
RAC Denial: H&P and discharge summary indicate
the patient was admitted with both sepsis and
cellulitis. Progress notes indicate the cellulitis was
the cause of the sepsis. Even though both conditions
were present on admission, we cannot choose
between the two as PDX in this case because the
coding rules indicate that we must sequence the code
for sepsis as principal diagnosis. The underlying
localized infection (cellulitis) is the secondary
diagnosis.
Sepsis and Aspiration Pneumonia
The Official Guidelines for Coding and Reporting
regarding two or more diagnoses that equally meet the
definition for principal diagnosis state, "In the unusual
instance when two or more diagnoses equally meet the
criteria for principal diagnosis as determined by the
circumstances of admission, diagnostic workup and/or
therapy provided, and the Alphabetic Index, Tabular
List, or another coding guidelines does not provide
sequencing direction, any one of the diagnoses may be
sequenced first."
If the reason for admission is sepsis (or severe sepsis or
SIRS) and a localized infection (such as cellulitis,
pyelonephritis, pneumonia, meningitis, cholangitis,
peritonitis, etc), the code for the systemic infection (e.g.,
038.X, 112.5, etc), is sequenced first, followed by code
995.91 or 995.92, and then the code for the localized
infection.
When Sepsis and aspiration pneumonia are both present
on admission, and neither one is ruled out during the
stay, and both were treated, coders can choose either
sepsis or aspiration pneumonia as the PDX. Before
assigning one or the other as PDX, it is the Coder’s or
Documentation Specialist’s responsibility to query the
physician to determine if the aspiration pneumonia is the
local source of the sepsis. Coding guidelines state that
the localized infection which entered the blood stream
must be a secondary diagnosis. If the physician
indicates that the local source of the sepsis is the
aspiration pneumonia, code the sepsis as PDX and the
aspiration pneumonia as secondary DX. If the aspiration
pneumonia is the not the cause of the sepsis, it can be
considered as a principal diagnosis. The physician
should add an addendum clearly stating there is no link.
However, look closely at the record, if the
documentation specifically supports that the patient is
admitted for the localized infection and the patient
develops sepsis/severe sepsis/SIRS after admission, the
localized infection should be sequenced first, followed
by the code for the systemic infection (e.g., 038.X,
112.5, etc), and then 995.91 or 995.92 as secondary
diagnoses. Query the physician if it is not clear if the
sepsis was present on admission or developed later.
Query the physician if the documentation does not link
the localized infection to the sepsis, severe sepsis, or
SIRS. Remember - SIRS codes to sepsis only when it is
linked to an infection. While the ICD-9-CM Official
Guidelines allow for pneumonia and urinary tract
infection to be designated as infections (which, for
pneumonia, is not always the case), other conditions that
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Sepsis
due
to
chronic
cholecystectomy performed
cholecystitis

and


Chapter specific guidelines take precedence over general
coding guidelines (AHA Coding Clinic 2003, first
quarter, page 15). Therefore, since the sepsis guidelines
are chapter-specific guidelines, the sepsis should be
sequenced as the principal diagnosis when a patient is
admitted with sepsis due to chronic cholecystitis.
It is the Coder or Clinical Documentation Improvement
Specialist’s responsibility to query the physician for
clarification to determine whether urosepsis means the
patient has septicemia or sepsis with a urinary tract
source or an infection contained within the urinary tract.
Use query form D attached.
Septic arthritis with sepsis
Septic arthritis is an infection contained to the affected
area. It is not a truly septic condition. A patient with
septic arthritis may not have sepsis. However, it is
possible to also have septic arthritis with sepsis.
Therefore, if the patient presents with both septic
arthritis and sepsis, then it would be appropriate to
sequence the sepsis as the principal diagnosis.
RAC Denial: Cases also are being denied when a
patient has "bacteremia," "sepsis," and "urosepsis"
documented in the medical record but only
"urosepsis" is documented on the discharge
summary. In this case, query the physician to clarify
which diagnosis was made after study.
Urosepsis and Sepsis due to urinary tract infection
Sometimes the clinical side and the coding side don’t
match up. A classic example is urosepsis, which to a
physician means “a patient who has a urinary tract
infection who also is septic or likely to be septic”. But
the documentation guidelines don’t allow for this
definition of urosepsis. In the coding guidelines,
urosepsis means just a simple UTI. So the physician
actually has to write UTI with sepsis. That doesn’t make
any sense from a clinical standpoint!
UTI with Presence of an Indwelling Urinary Catheter
and Septicemia
Foley catheters are considered indwelling urinary
catheters; however, so are suprapubic cystostomies,
percutaneous nephrostomies, and internal ureteral stents.
Septicemia due to an indwelling urinary catheter is
assigned code 996.64, infection and inflammatory
reaction due to internal prosthetic device, implant and
graft, and is sequenced as the principal diagnosis. A
secondary diagnosis code from category 038 and a code
for the organism responsible must be assigned, if not
indicated by the septicemia code, and sequenced as a
secondary diagnosis (AHA Coding Clinic 1993, third
quarter, page 6.)
Even so, the coding guidelines for urosepsis remain the
same. If only urosepsis was documented, then code
599.0 would be assigned. However, coders and/or
documentation improvement specialists should not be
satisfied with coding UTI for a diagnosis of Urosepsis if
the documentation contains clinical signs of septicemia:


Leukocytosis/leukopenia (WBC less than 3,000
or more than 12,000)
Blood culture may be positive or negative
LOS often is greater than 3 days but not
mandatory
Fever, chills, malaise, hypotension, tachycardia,
tachypnea, confusion, altered mental status
IV broad spectrum antibiotic and push fluids
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Septicemia due to Gastrostomy Infection
RAC Denial: An underpayment determination was
made by the RAC in a case where Septicemia was
due to an UTI and the UTI was documented as due to
an indwelling urinary catheter.
Septicemia was
submitted as the PDX. The RAC correctly re-coded
the case with 996.64 as the PDX resulting in a higher
paying DRG.
Septicemia due to an infection of a gastrostomy is
assigned code 536.41 plus 038.x. (AHA Coding Clinic
1998, fourth quarter, pages 42 and 43.)
Septicemia due to Colostomy and Enterostomy
Infection
Septicemia due to an infection of a colostomy or
enterostomy is assigned code 569.61, infection of
colostomy and enterostomy plus 038.x, septicemia
(AHA Coding Clinic 1998 fourth quarter, page 44).
In those cases where a UTI and a urinary catheter are
both present but not linked by the physician, it is always
right for the Coder or CDI Specialist to query the
physician to clarify whether or not the UTI was due to
the catheter. Don’t leave money on the table for your
organization!
Staph Aureus Septicemia due to Tracheostomy Site
Infection
Septicemia from an infected tracheostomy site due to
Staphylococcus aureus is assigned code 519.11,
infection of tracheostomy and 038.11, Staphylococcus
aureus septicemia (AHA Coding Clinic 1998 fourth
quarter, page 42).
Line Sepsis versus Line Septicemia
A diagnosis of septicemia due to a vascular access
device requires two codes. The principal diagnosis is
996.62, infection and inflammatory reaction due to other
vascular device, and a code from category 038,
septicemia is sequenced as a secondary diagnosis.
Without the documentation of “sepsis” or “SIRS”, a
code from subcategory 995.9, systemic inflammatory
response syndrome (SIRS), would not be assigned (AHA
Coding Clinic 1994 second quarter, page 13). On the
other hand, Sepsis due to a vascular access device is
assigned code 996.62, infection and inflammatory
reaction due to other vascular catheter followed by the
appropriate sepsis code from category 038 and a code
from subcategory 995.9, systemic inflammatory
response syndrome (SIRS). If organ dysfunction is
present, codes should be added to identify the specific
type of organ dysfunction (AHA Coding Clinic 2004,
second quarter, page 16).
Sepsis due to a Postprocedural Infection
Documentation of causal relationship must exist in the
medical record.
As with all postprocedural
complications, code assignment is based on the
provider’s documentation of the relationship between the
infection and the procedure. In cases of postprocedural
sepsis, the complication code, such as code 998.59,
Other postoperative infection, or 674.3x, Other
complications of obstetrical surgical wounds should be
coded first followed by the appropriate sepsis codes
(systemic infection code and either code 995.91or
995.92). An additional code(s) for any acute organ
dysfunction should also be assigned for cases of severe
sepsis.
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Biliary Septicemia due to Percutaneous Transhepatic
Cholangiogram
Neutropenic sepsis
Neutropenic sepsis is assigned code 038.9, unspecified
septicemia, followed by neutropenia, 288.0 (AHA
Coding Clinic 1996, second quarter, page 6).
Biliary septicemia due to percutaneous transhepatic
cholangiogram is assigned code 998.59, other
postoperative infection and 038.x, septicemia (AHA
Coding Clinic 1995, second quarter, page 7).
Nadir sepsis
Nadir sepsis is assigned code 038.9, unspecified
septicemia, followed by code 288.0, neutropenia (AHA
Coding Clinic 1996 third quarter, page 6).
New RAC Issues
The recovery audit contractors must have new issues approved by CMS before they can start sending out record
requests. CGI is our regions recovery audit contractor. CGI has added the following new issues this summer:
MS-DRGs 255-257
Upper limb and toe amputations for circulatory
disorders
MS-DRGs 280-285
Acute myocardial infarction
MS-DRGs 288-290
Acute and subacute endocarditis
MS-DRGs 294-295
Deep vein thrombophlebitis
MS-DRGs 296-298
Cardiac arrest
MS-DRGs 299-301
Peripheral vascular disorders
MS-DRGs 332-334
Rectal resection
MS-DRGs 338-343
Appendectomy
MS-DRGs 344-346
Minor small and large bowel procedures
MS-DRGs 347-349
Anal and stomal procedures
MS-DRGs 408-410
Biliary tract procedures
MS-DRGs 420-525
Hepatobiliary procedures
MS-DRGs 559-561
Aftercare musculoskeletal system
MS-DRGs 641-645
Nutritional and endocrine disorders
MS-DRGs 969-970 and 974-977
Human Immunodeficiency virus infections
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Current RAC Audit
RAC Audit July 2011
We received a request for 196 records from 7 acute care facilities on 35 different issues.
The top 5 requests for DRG included:

MS-DRG 216-221 – Cardiac Valve and Other Cardiothoracic Procedures (total of 28 records from 3 facilities)

MS-DRG 329-331 – Major Small and Large Bowel Procedures (total of 30 records from 5 facilities)

MS-DRG 335-337 and 350-355 – Lysis of Adhesions (total of 10 records from 3 facilities)

MS-DRG 411-419 – Cholecystectomy (total of 9 records from 4 facilities)

MS-DRG 461-462, 466, 468 and 470 – Major Joint Procedures (total of 8 records from 3 facilities)
These requests also are looking for the inpatient admitting order
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