Sepsis Documentation and Coding Guidelines (2020 Update)

Post updated with 2020 guidelines on December 2019 by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10- CM/PCS Trainer.

We know that SEPSIS is a life-threatening condition and there has been much discussed about this subject in many clinical circles as well as in clinical coding and clinical documentation improvement (CDI). The golden rule for the HIM Coding and CDI professional is that we must have the diagnostic documentation by the provider in order to assign the ICD-10-CM code(s) and follow Official Guidelines.

CLINICAL OVERVIEW: Before we can discuss the ICD-10-CM coding of Systemic Inflammatory Response Syndrome (SIRS) and Sepsis, we need to have a clear understanding of the many clinical criteria that tell us SIRS is a precursor to Sepsis, which can lead to Severe Sepsis, that can then lead to Septic Shock.

Over the years there have been many clinical experts, medical journals and medical societies publish information about SIRS and Sepsis. A medical consensus on SIRS and Sepsis was published in 1991-1992 (Referred to as Sepsis 1), the SIRS criteria included two or more of the following (keep in mind that each patient is different so the signs/symptoms will vary):

• Fever/Temperature >38°C or <36°C (some research states >38.3°C)

• Tachycardia/Heart rate >90/min

• Tachypnea/Respiratory rate >20/min or PaCO2 <32 mm Hg (4.3 kPa)

• Leukocytosis/White blood cell count >12 000/mm3 or <4000/mm3 or >10% immature bands

According to this initial research study, if SIRS was present and there was an infection then a diagnosis of “Sepsis” could be made.

In 2001 additional research consensus on Sepsis was published (called Sepsis 2) indicating that in addition to the 1991 criterion on SIRS, that there were other more specific clinical signs to consider when diagnosing SIRS included a change in mental status and several clinical/lab values that were not included in Sepsis 1:

• significant edema or positive fluid balance (20 mL/kg over 24 hours);

• hyperglycemia (plasma glucose 120 mg/dL or 7.7 mmol/L) in the absence of diabetes;

• plasma C-reative protein (> 2 SD above the normal value);

• plasma procalcitonin (> 2 SD above the normal value)

Beginning in 2003 the “Surviving Sepsis Campaign” started focusing on decreasing sepsis mortality and bringing more attention to the condition of sepsis. The criterion that was published was more specific (i.e. temperature of 101°C or higher) than the prior medical journals. Severe sepsis was felt to be Sepsis with organ dysfunction, but again, each patient is different, so providers need to make their own determination of whether a patient is septic or not.

By 2015, the Centers for Medicare and Medicaid (CMS) and the Joint Commission (TJC) developed a Core Measure Sep-1 to help identify sepsis and decrease mortality. Their criteria were and are a little different from the ones above which may lead to confusion and documentation issues.

In 2016, researchers and clinical experts published the consensus for a Sepsis -3 definition, stating: Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Clinically “Septic shock” would appear and be diagnosed when the patient has become hypotensive (i.e., less than 90 mmHg or a 40% drop in mmHg from previous normal blood pressure). They also stated that “severe sepsis” was a redundant term and definition so it was not further addressed. As part of the Sepsis-3 publication, the Sequential Organ Related Assessment or SOFA and quick-SOFA or q-SOFA were introduced as a valuable tool to identify organ dysfunction and septic shock.

There continues to be significant clinical research and work to standardize clinical terminology and clinical criteria, so we can expect more attention surrounding SIRS and Sepsis.

ICD-10-CM OVERVIEW: When performing clinical coding and auditing, we must always follow the ICD-10-CM Official Guidelines for Coding and Reporting, which can be located at: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-Coding-Guidelines.pdf

Guidance and direction published in the American Hospital Association ICD-10-CM/PCS Coding Clinic should also be adhered to.

ICD-10-CM Chapter 1 Certain Infectious and Parasitic Diseases, contains specific guidelines relating to the coding of Sepsis, Severe Sepsis and Septic Shock, although there is one guideline listed in Chapter 15 Pregnancy Childbirth and Puerperium, Chapter 16 Certain Conditions Originating in the Perinatal Period and in Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings; all should be reviewed and followed regarding Sepsis as well.

In Chapter 1 the code range A40 – A41.9, classifies several types of bacterial sepsis but also includes “Sepsis, unspecified organism”. When assigning a code for SIRS and Severe Sepsis, Chapter 18 is where the codes are located:

• R65.1 Systemic inflammatory response syndrome (SIRS) of non-infectious origin

• R65.10 Systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction

• R65.11 Systemic inflammatory response syndrome of non-infectious origin with acute organ dysfunction

• R65.2 Severe Sepsis

• R65.20 Severe Sepsis without Septic Shock

• R65.21 Severe Sepsis with Septic Shock

With the difference between the above clinical definitions of the condition and the way the coding classification has listed the codes, there have been suggestions made to revise the classification to better align with clinical terminology and meaning, so stay tuned for possible ICD-10-CM changes to come in the future.

REMEMBER:

• The code for the systemic infection should be assigned first, followed by a code for the localized infection (for example pneumonia);

• If the patient is admitted with a localized infection, and develops Sepsis after admission, a code for the localized infection is assigned first, followed by a code for the Sepsis or Severe sepsis;

• If the organism causing the Sepsis is documented, use a code in subcategory A41 (e.g., A41.51 Sepsis due to E. coli);

• Severe sepsis requires at least 2 ICD-10-CM codes; a code for the underlying systemic infection and a code from category R65.2 Severe Sepsis; you should also assign a code(s) for the acute organ dysfunction if documented;

• Codes R65.20 and R65.21 as not acceptable as Principal diagnosis and must be sequenced after a code for the underlying systemic infection;

• A code from ICD-10-CM code subcategory R65.2- (severe sepsis) would not be reported unless the physician has documented severe sepsis or an acute organ dysfunction;

• Currently, when there is documentation of Severe sepsis, there should be evidence of organ dysfunction or perfusion