Septicemia/Sepsis Slides

Documentation, Coding Audit, and Appeal Workshops
Sponsored by Intersect Healthcare Inc.
Healthcare, Inc

Part One:
Septicemia/Sepsis Workshop
(MS DRG s
(MS-DRG’s 870, 871-872)
871 872)

Next Session:
Wednesday, June 23
1:00PM
1 00PM EST
Respiratory Failure
with Ventilator Support

1

Healthcare, Inc

Part One:
Septicemia/Sepsis Workshop
(MS-DRG’s 870 871 872)
(MS DRG’ 870, 871-872)

Your Panel:

Joel Moorhead, MD, PhD 1:00-1:30 pm
Documenting Septicemia/Severe Sepsis

Charmira Johnson, CCS, BS, LPN, CCDS 1:30-2:00 pm
Coding/Audits for Septicemia/Severe Sepsis

Denise Wilson, RN, RRT, MS 2:00-2:30 pm
Appealing Septicemia/Severe Sepsis Takebacks

2

Joel Moorhead, MD, PhD
Adjunct Associate Professor
Rollins School of Public Health
Emory University
Atlanta, GA

3

• Documentation to support diagnosis of
SIRS and sepsis

• Infectious versus non-infectious SIRS

First Things First Planning
• Severe sepsis

• SIRS with organ dysfunction

• Associated conditions

(c) 2010 Intersect Healthcare, Inc. 4

4

• Inflammation is body’s NORMAL response
body s
to infection, chemical exposure, or trauma

– Stage I: Initiation of inflammatory
response
p
• WBCs secrete proteins (cytokines) that promote
healing
– Chemical messengers that promote tissue repair

– Stage II: Control of local inflammatory
response
• Decrease in chemicals that promote inflammation
• Increase in chemicals that reduce inflammation
• Homeostasis maintained
– Bone RC. Critical Care Medicine 1996;24:163-172


5

– Inflammation Stage III
• Body loses control
• Homeostasis cannot be restored
• Cytokine activity becomes destructive
– Capillaries damaged
– Multiple organs may be damaged
» Bone RC. Critical Care Medicine 1996;24:163-172



6

• Age >65
Age >65
• Immunosuppression
– Steroids, chemotherapy, immunosuppressant drugs
– AIDS and other chronic immunological disorders
• Alcohol abuse
• Malnutrition
• First Things First Planning
Invasive instrumentation
• Persistent inflammatory or infectious focus
• Chronic disease, e.g. COPD, DM, CAD, renal
failure
f il
• Kohl BA and Deutschman CS. Current Opinion in Critical Care 2006;12:325‐332


7

• Infection
– Inflammatory response caused by
microorganisms
• Bacteremia
– Bacteria in the blood
• SIRS
First Things First Planningof
– Inflammatory response, independent
cause
• Sepsis
– SIRS arising from infection
– Bone RC et al. Chest 1992;101:1644-1655


8

• 995 9 Systemic Inflammatory
995.9
Response Syndrome (SIRS)
– 995.91 Sepsis
• SIRS due to infectious process without acute organ
dysfunction
– 995.92 Severe sepsis
• Sepsis with acute organ dysfunction
• Sepsis with multiple organ dysfunction (MOD)
– 995.93 SIRS due to non-infectious process
without acute organ dysfunction
with acute organ dysfunction


9

• ACCP/SCCM Consensus Conference
(1991)
• SCCM/ESICM/ACCP/ATS/SIS Consensus
Conference (2001)
– ACCP: American College of Chest Physicians
– SCCM: Society of Critical Care Medicine
– ESICM: European Society of Intensive Care
Medicine
– ATS: American Thoracic Society
– SIS: Surgical Infection Society

(c) 2010 Intersect Healthcare, Inc. Copyright 2009 5
10

10

1991 ACCP/SCCM 2001 ACCP/SCCM…Update
• Infection with at least • Infection documented or
two of the following, suspected and “some of ” …
not due to other – General parameters
cause: • Temp >38.3° C or <36 ° C
– Temp >38° C or <36 ° C • HR >90 or 2 SD > age mean
• >100.4° F or <96.8 ° F • RR >30 per minute
– HR >90 per minute – Inflammatory parameters
– Hyperventilation • WBC >12,000 or <4000 /μL
– RR >20 per minute • Or >10% bands
– PaCO2 <32 mm Hg
– Hemodynamic parameters
– WBC >12,000 or <4000
/μL – Tissue perfusion parameters
– Levy MM et al for the International
• Or >10% bands Sepsis Definitions conference.
– Bone RC et. al., Chest Intensive Care Medicine 2003;29:530-
1992;101:1644-1655 538


11

• Fever (core temperature >38.3° C)
• Hypothermia (core temperature <36° C)
• HR >90 or >2 SD above normal value for age
• Tachypnea: >30 per minute
• Altered mental status
Alt d t l t t
Significant edema or positive fluid balance
• Hyperglycemia (>110 mg/dl in absence of DM)
– Levy MM et al for the International Sepsis Definitions conference.
Intensive Care Medicine 2003;29:530-538


12

• Leukocytosis (WBC >12,000/ /μL)
• Leukopenia (WBC <4000 /μL)
• Normal WBC with >10% immature forms
– Usually reported as “Bands”
• Plasma C reactive protein >2 SD above normal
Plasma procalcitonin >2 SD above normal


13

• Hypotension (Psys<90 mm Hg or ↓>40 mm Hg)
• Organ dysfunction parameters
– Number of failing organs or composite score (e.g.
MODS)
• Hypoxemia (PaO2/FIO2 <300)
• Acute Oliguria (urine output <0.5 ml/kg/h 24 h)
•
•
Creatinine increase ≥0.5 mg/dl
Coagulopathy (INR >1.5 or activated PTT >60
seconds)
• Ileus (absent bowel sounds)
• Thrombocytopenia (platelet count <100,000/μl)
<100 000/μl)
• Hyperbilirubinemia (plasma total bilirubin >4
mg/dl)

14

• Hyperlactatemia (>3 mmol/l)

• Decreased capillary refill or mottling
• Levy MM et al for the International Sepsis Definitions conference. Intensive
Care Medicine 2003;29:530-538
2003;29:530 538


15

• 995.9 Systemic Inflammatory
Response Syndrome (SIRS)
– 995.91 Sepsis
dysfunction
– 995.94 SIRS due to non-infectious process with
acute organ dysfunction

16

16

• Six measures, scale of 0 (normal) to 4 (marked
derangement)
– Respiratory - PaO2/FIO2 ratio
– Renal – Serum creatinine concentration
– Hepatic – Serum bilirubin concentration
– Hematologic – Platelet count
–
– First Things First Planning
Central nervous system – Glascow Coma Scale
Cardiovascular – HR x (central venous pressure/mean
arterial pressure)
• MOD score and hospital mortality
– 9-12: 50% hospital morality
– 13-16:
13 16: 70% hospital mortality
– 17-20: 82% hospital mortality
– 21-24: 100% hospital mortality
– Marshall JC et al. Multiple Organ Dysfunction Score. Critical Care Medicine 1995;23(10):1638-1652

17

17

• History of chronic organ insufficiency or
immunocompromise?
• Acute renal failure?
• Age
• Vital signs
– Temperature, HR, RR
Lab values
– pH, sodium, potassium, creatinine, hematocrit, WBC, PaO2,
alveolar-arterial O2 gradient
• Apache II score 21-25: Predicted mortality 50%;
26-30: 70%
– Patients with sepsis may have higher-than-predicted
mortality
– Lee KH et al. Singapore Med J 1993;34:41-44


18

Organ System Sign of Dysfunction
• Cardiovascular • ↑HR, ↓ BP, edema
↓ capillary refill,
skin mottling

• Pulmonary
P l • Tachypnea, hypoxemia

• Renal • ↑ Creatinine, oliguria

• Hepatic • Hyperbilirubinemia

• Gastrointestinal • Ileus
– Based on Levy MM et al for the
International Sepsis Definitions
conference. Intensive Care Medicine
2003;29:530-538


19

Organ System Sign of Dysfunction
• Neurological • Altered mental status

• Hematologic • Leukocytosis, leukopenia,
>10% bands,
thrombocytopenia,
coagulopathy

• General and Metabolic • Fever, hypothermia,
hyperglycemia,
↑ C-reactive protein
p
– Based on Levy MM et al for the
International Sepsis Definitions
conference. Intensive Care Medicine
2003;29:530-538


20

• 995.92 S
99 92 Severe S Sepsis
i • Acute kid
kidney injury
i j
and • Acute respiratory failure
• 995.94 SIRS due to • Critical illness
non-infectious process myopathy
with acute organ • Critical illness
dysfunction polyneuropathy
l th
– Code first underlying
infection • Disseminated
– Use additional code to intravascular
specify acute organ coagulopathy syndrome
dysfunction, such as …
• Encephalopathy
• Hepatic failure
H ti f il


21

• 995.9 Systemic Inflammatory Response
Syndrome (SIRS)
– 995.91 Sepsis
dysfunction
– 995 94 SIRS due to non-infectious process with
995.94 d t i f ti ith
acute organ dysfunction


22

• Lab tests f
b favoring
i • Non-infectious condition →
N i f ti diti
infection that results in SIRS,
infectious SIRS
(probably little help for coding)
see Section 1.C.17.b.12.
– ICD-9 Official Guidelines for Coding and
– ↑ C-reactive protein Reporting, Section 1.C.17.g

– ↑ Procalcitonin (cytokine) • If sepsis meets definition of
– ↓ Eosinophil count principal diagnosis, sequence
septicemia before the non-
non
infectious condition
• Only an issue if both • When both the non-infectious
infectious and condition and the infectious
condition (sepsis) meet the
noninfectious causes definition of principal
are present in same diagnosis, either can be
patient assigned as principal
diagnosis.
– ICD-9 Official Guidelines for Coding and
Reporting, Section 1.C.1.b.12.


23

• Trauma • Surgery
– Kohl BA, Deutschman CS. klCurr Opin Crit
• Pancreatitis Care 2006;12:325-332

• Ischemia • Medications
– Coding Clinic 1st Quarter 2010, pages 10-11

• Hemorrhagic shock • Malignant neoplasm
• Immune-mediated • Other types of
organ injury inflammatory
• Bone RC. JAMA 1992;268(24):3452-
3455
conditions
– Coding Clinic 1st Quarter 2010, page 10


24

• Aspiration • Autoimmune
Pneumonia (507.0)
P i (507 0) diseases
di
indexed under – Systemic lupus
– Rheumatoid arthritis
Category 507
– Sarcoidosis
Pneumonitis due to
solids and liquids
q • Associated
– No infectious examples
conditions
diti
– Liver
– Aspiration + infection? • Hepatitis
• If aspiration led to infectious • Primary biliary cirrhosis
pneumonia after admission,
the infectious condition was – Kidney
not present on admission and • Nephritis
was not eligible for principal • Glomerulonephritis
diagnosis.
diagnosis
– GI
• Crohn’s disease
• Ulcerative colitis

(c) 2010 Intersect Health care, Inc. 25

25

• Risk factors • Clinical syndrome
– Prolonged rupture of – Signs of circulatory
g y
membranes compromise in first month
of life
– Pre-term labor
• Pallor, poor perfusion
– Maternal fever • Hypotonia
– Unhygienic postnatal • Poor responsiveness
care
– Low birth weight
• PDx 771.81 Septicemia of
– Feeding of newborn (not 038.xx)
contaminated foods
– 041.xx Bacterial infection
and fluids
– If applicable …
• 995.92 Severe sepsis
• Acute organ dysfunction code
– Edmond K, Zaidi A. PLoS Medicine
2010;7(3):e1000213


26

SIRS SEPSIS
• Antibiotics when • Broad-spectrum antibiotics
– Immunocompromised • Crystalloid, vasopressors
– Hemodynamically – Hypotension
unstable
– Infection suspected
• Low-dose steroids for septic
shock
• IV fl id vasopressors
fluids,
– Hypotension • Control blood glucose levels
• Treatment of • Treatment of complications
complications • Drotrecogin alfa (Xigris®)
• Control of blood – Recombinant protein C
glucose levels – Anti thrombotic
Anti-thrombotic
– Anti-inflammatory
• Oxygen – Used when risk of mortality
• Burdette SD, Parilo MA.
Emedicine.medscape.com/article/ high
168943-print


27

• 2004 Survey of 1058 physicians
– Only 17% agreed on any one definition of sepsis

• Multiple signs and symptoms
– None are specific for sepsis

– All signs and symptoms can vary among patients and
within the same patient over time
– Signs and symptoms should not be due to any other cause
• But other causes are almost always present
– Acute organ dysfunction must be associated with sepsis
• Elevated liver function tests in patient with autoimmune hepatitis
probably associated with hepatitis rather than sepsis

• Single definition of sepsis may never be possible
• Vincent J-L et al . Evolving concepts in sepsis definition. Critical Care Clinics
2009;25:665-675

28

28

• If the patient isn’t really sick, he or she probably
isn’t
i ’ septic.
i
– Physicians almost always dictate a level of concern about
a seriously ill patient.
• Look for basic consensus criteria to support
diagnosis of sepsis.
• Clarify whether sepsis is secondary to an
infectious or a non-infectious process.
•
Look for conditions under all the parameters from
the 2001 International Sepsis Definitions
Conference to support the presence of acute
organ dysfunction.
• Consider all diagnoses or medical terms
corresponding to each organ dysfunction to
identify all conditions eligible for coding.

29

29


30

Charmira Orr, BS, LPN, CCS, CPC, CCDS
Director of Coding and Audit Services
Intersect Healthcare, Inc.
,

31

• Understand how to apply the ICD-9 CM
coding and sequencing guidelines to
assign related codes for Septicemia,
SIRS, and Sepsis

• The RAC, Septicemia, and Severe Sepsis
• Auditing the Medical Record for
Septicemia, SIRS, and Sepsis
documented diagnosis


32

• Defined as a “systemic” condition or major complication
that is associated with pathogenic organisms like fungi,
bacteria, and etc. in the blood stream.
• O38* Series are MCC conditions
• Other types of septicemia classified to another organism
can be found in the Index-under Septicemia such as
conditions like Herpetic Septicemia 054 5 or Anthrax
054.5
Septicemia 022.3 also MCC Conditions
It is an Infection from the entrance of the organisms in the
blood
• Not to be confused with Bacteremia – in which is bacteria
that has entered into the blood stream and if not stopped
leads to the “systemic” infection that causes Septicemia
• Needs to be specifically documented by physician and
alone does not mean the patient has Sepsis
• Can have negative or inconclusive blood cultures


33

DRG RW GMLOS
DRG 791 Prematurity
y RW 3.2039 GMLOS 0.0
with Major Problems

MS‐DRG 974 HIV RW 2.5656 GMLOS 7.3
with Major Related
Conditions with a
MCC
MS‐DRG 870 RW 5.7258 GMLOS 12.9
Septicemia or Severe
Sepsis with
h
Mechanical
Ventilation 96+ Hours
MS‐DRG 871 RW 1.8222 GMLOS 5.5
Sepsis w/o
Mechanical
Ventilation 96 +
Hours with MCC
MS‐DRG 872 RW 1.1209 GMLOS 4.7
Sepsis w/o
Mechanical
Ventilation 96+ hours
w/o MCC


34

• Systemic Inflammatory Response Syndrome
• DEF: As a “acute” clinical response to an infection insult
acute infection, insult,
or other trauma
• Subcategory 995.9
• When assigning must have two (2) codes to describe Can
never be assigned as a Principal Diagnosis- must sequence
first the underlying cause then code 995.9
• Must monitor for Infection and Noninfectious process data
within the medical record
According to the American College of Chest Physicians and
the Society of Critical Care Medicine, the clinical
manifestations of SIRS include: Must Have at Least 2 of
the manifestations to assign SIRS
– Temperature >38° or <36° C, rectally
– Tachycardia >90 BPM
– Tachypnea >20 breaths per minute or
– arterial pCO2 <32mm Hg
– WBC >12,000/mm2 or <4,000/mm2
– or >10% band


35


36

Infection SIRS SEPSIS


37

• Defined as the body’s systemic inflammatory response to an
infection in the body that can originate from anywhere in
the body, however does not cause “acute” organ
dysfunction
• Underlying infection can be suspected or proven infection
• Two (2) or more of the clinical findings of SIRS not
attributable to any other cause
• Infection + SIRS = SEPSIS
• ICD-9
ICD 9 Code 995 91 excludes 995.90 SIRS, NOS
995.91 995 90 SIRS
•
•
IT is a MCC
Must be documented by the physician in order to assign
code
• Minimum of two ( 2) codes for proper coding, with
underlying infection sequenced before 995.91


38

• Severe Sepsis includes the same definitive data
Sepsis-
as Sepsis but extends to organ dysfunction. i.e.
Acute renal failure (creatinine > 2 x ULN or
baseline)
– ARDS (PaO2/FiO2 < 250)
– DIC (thrombocytopenia— platelet count <100,000)
– Encephalopathy
–
– First Things First Planning
Hepatic failure (bilirubin or SGOT)
“Acute "Organ failure must be specifically documented that it is
related to Sepsis by the physician
– Has a longer length of stay
– Higher mortality rate
– Often treated in ICU
• Minimum of three (3) codes sequencing first the
underlying condition, then 995.92, then a
additional code for the “acute” organ dysfunction


39

• Issue Details Name Septicemia DRG 416, 576 MS-DRG 870, 871, 872 (At this time,
MS DRG
Medical Necessity is excluded from review.) Number B000442009 Description The
purpose of MS-DRG Validation is to determine that the principal diagnosis and all
secondary diagnoses identified as CCs and MCCs are actually present, correctly
sequenced, and coded. When a patient is admitted to the hospital, the condition
established after study found to be chiefly responsible for occasioning the
admission to the hospital should be sequenced as the principal diagnosis. The
other diagnosis identified should represent all (MCC/CC) present during the
admission that impact the stay. The POA indicator for all diagnoses reported must
be coded correctly. Reviewers will validate for MS DRG 870, 871, and/or 872,
principal diagnosis, secondary diagnosis, and procedures affecting or potentially

affecting the DRG. Claim Type Inpatient Issue Type Complex Overpayment /
Underpayment Overpayment and Underpayment Dates of Service 10/1/2007 -
Open States IL, IN, KY, MI, MN, OH, WI Policy Related Links ICD-9-CM Coding
Manual (for dates of service on claim)
• ICD-9-CM Addendums and coding clinics
– PIM Ch 6.5.3, Section A - C - DRG Validation Review
– Present on Admission Indicator Systems Implementation
– OIG Report DRG 416: Septicemia, August 1989 (1)
– OIG Report DRG 416: Septicemia, August 1989 (2)
Date Approved 12/4/2009
© 2009 CGI Federal


40

Principal Diagnosis - defined by UHDDS as the condition
p g y
established after study to be chiefly responsible for
admission of the patient to the hospital
When Sepsis, or severe sepsis meets Principal Diagnosis
definition, the following assignments are made:
1. Assign first the code for the underlying systemic infection (038.xx or
112.5 )
2. Then must assign Code 995.91 Sepsis or 995.92 Severe Sepsis (Organ

3.
Failure)
Assign a code if applicable for any localized infections (i.e. pneumonia,
cellulitis, etc.)
4. Must also code for any “ acute” organ dysfunction if you document 995.92

Secondary Diagnosis - If sepsis or severe sepsis developed
after admission.
– In order to assign a code from 998.9 the term sepsis or SIRS must be
documented by the physician


41

Examine

Query Review

Track
Documentation Abstract
Data

Identify Code

Compare


42

1. Examine - The medical record to ensure that it is a
complete record. Physician attestation statement and
Discharge Summary is on the record, as well as nurses
notes, treatment records and etc..

2. Review - Must review the Entire Medical Record to
2 R i
accurately assign the principal and secondary
diagnosis

3. Abstract - Data from the Medical Record – Worksheet


43

1. Principal diagnosis________________________________________________
2. Is this the same diagnosis as the admitting diagnosis? Y N
3. Presenting symptoms upon admission: (Know the Indicators)

Septicemia/Sepsis/SIRS I di
S i i /S i /SIRS Indicators
Acute mental status changes
Positive blood culture
Fever > 100.4 F or <97 F
Heart Rate > 90BPM
Respiratory Rate > 24 breats/minute
Elevated WBC > 12,0000 or < 4,000
Physician documentation of decreased urine output ‘ oliguria”

Severe Sepsis/Septic Shock Indicators

Thrombocytopenia PLT Count <100,000
Decreased peripheral pulses
Hypotension SBP < 90mmHg or SBP decrease >40mmHg
Creatine > 2.0 or increase . 0.5 mg/dl
Coagulation issues INR > 1.5 or PTT >60 secs.
Arterial pH < 7.30

4.
4 Physician documentation and date of diagnosis for Sepsis, SIRS, Shock
Ph i i d t ti dd t f di i f S i SIRS Sh k
states:__________________________________________________________
5. Patient Vital signs of date of diagnosis:_________________________________
6. Any applicable lab values for diagnosis: ( Check WBC’s, PLTS) TRACK DATES WHEN COMPLETED
Blood cultures result: (IF POSITIVE, LIST ORGANISM)


44

7. Was the patient started on antibiotics, clotting factors, platelets, or given XIGRIS? Y N
Was patient on antibiotics prior to admission? Y N
8. Does the physician document any underlying infections? Y N (Date Reported and Treatment
Implemented)
9. Is there any evidence of any organ dysfunctions or failures? Y N ( Date Reported and Treatment
Implemented)
10.
10 Is there documentation to support that this organ failure is related to sepsis and if so where: (
Document location in medical record)
11. Any other types of trauma, malignant neoplasm’s, or inflammation such as
pancreatitis?_______________________________________________________
12. Were any devices in use and attributed to diagnosis ( i.e. Foley, VAD, tracheostomy, gastrostomy):
Y N
13. Date and time if applicable of endotracheal intubation for
ventilation:________________________________________________________
Was patient discharged or transferred while intubated:_____________________
If applicable date and time patient was extubated:_________________________
Was ET or Tracheostomy performed in inpatient status? ____________________

Date and time mechanical ventilation was initiated? _______________________
Was patient weaned during time on the vent? If so hours___________________
Date and time mechanical ventilation ended:_____________________________
Was the patient completely weaned off the vent, and restarted within any time frame during
the same admission? Yes or No, If applicable list dates______________________

Discharge status: ( Transfer MS-DRG)
Home or Self Care -01
Discharged/ Transferred to a Short Term General Hospital for Inpatient Care -02
Discharged/ Transferred to a SNF with Medicare Certification in Anticipation of killed Care - 03
Discharged/Transferred to an Intermediate Care Facility - 04
Discharged/Transferred to Another Type of Health Care Facility Not elsewhere in the Code List- 05
Discharged/ Transferred to Home Care- 06
AMA -07
Expired-20


45

4. Code - Reviewer will code from data that they
abstracted

5. Compare - codes that they assign to the codes that
were billed

6. Identify - any areas in the medical record for areas of
uncertainty and di
t i t d discrepancies
i
7. Track Data Collected - Highlight areas, photocopy
areas in question to possibly highlight for physician

8. Query - the provider on any discrepancies found. Send
them the highlighted portions of the medical record so
that they can view. DO not lead .. Only identify what is
in the record and ask for clarification

46

Case Scenario
• A 71 year old male with a history of COPD, DM, recent pulmonary embolism, and CHF was
admitted from the emergency room after being transferred from a SNF with
g y g
unresponsiveness. While in the ER the patient was noted with abnormal blood gases after
failing a BIPAP test.

• Subsequently he was intubated and placed on mechanical ventilation. Labs conducted in the
ER revealed the patient to have a WBC 11.6, Hgb 11.7 , HCT 38.9, PLTS 330,000, Creatine
0.5. Blood and sputum cultures drawn.. CXR revealed an infiltrate in the right stem bronchus.
VS in ER 98.6, 112, 90/76 14.

• Patient was admitted with Acute Respiratory Failure, Pneumonia, and Probable Sepsis.

During the course of the admission the initial blood cultures taken in the ER were negative in

•
growth. However, the sputum cultures identified H. Influenza in which was sensitive to all
antibiotics, in which the patient continued on. However, the patient began to expectorate
thick tenacious and copious amounts of sputum and a second set of sputum cultures on the
5th day of the stay were taken and later revealed the patient to have MRSA that was only
sensitive to Vancomycin, in which was initiated.

• During the course of the admission the patient was treated with IV antibiotics for pneumonia
and was later ex-tubated after the 10th day of the admission and transferred back to the SNF
on oral antibiotic Levaquin. Sepsis was only mentioned at the admission and discharge.
• On the discharge summary the discharge diagnoses stated resolved sepsis, resolved acute
respiratory failure, acute exacerbation of COPD, H. Influenza pneumonia, and MRSA resistant
pneumonia.

• This record was billed at DRG 870 Septicemia or Severe Sepsis w/ + 96 hours of Mechanical
Ventilation. Was this the correct MS-DRG assignment?


47

• Admitted with sepsis, pneumonia, and
respiratory failure
i f il
According to AHA Coding Clinic for ICD-9-CM, a patient admitted with
pneumonia and sepsis goes to sepsis as the principal diagnosis (2003,
fourth quarter, pages 79-81). A patient admitted with pneumonia and
respiratory failure goes to respiratory failure as the principal diagnosis
(2003, second quarter, pages 21-22). When a patient is admitted with
respiratory failure due to or associated with an acute nonrespiratory
condition (sepsis), then the acute nonrespiratory condition is
( p ), p y
sequenced as the principal diagnosis (1991, second quarter, pages 3-
5). Since respiratory failure is an organ dysfunction of SIRS/sepsis, it
should be listed as a secondary diagnosis. Therefore, if a patient is
admitted with 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, if the
documentation specifically supports that the respiratory failure was
caused by another respiratory condition and not caused by the sepsis,
y p y y p ,
then it may be appropriate to sequence the respiratory failure as the
principal diagnosis


48

• Lack of documentation to substantiate a diagnosis of septicemia/sepsis
although some symptoms are present.

• Generalized septicemia/sepsis is being coded based on the physician’s
diagnosis of septicemia/sepsis in the medical record; however, review of
medical record documentation reveals that only a few symptoms, such as
high fever and leukocytosis, are present. Coders must seek clarification
from the physician regarding the presence of septicemia/sepsis when
f h h i i di h f i i / i h

only isolated symptoms are documented in the medical record and code
accordingly. It should be noted that negative or inconclusive blood
culture findings do not preclude a diagnosis of septicemia/sepsis in
patients with clinical evidence of the condition. Coders should learn to
recognize the clinical picture of septicemia/sepsis so as to be able to
identify when the diagnosis of septicemia/sepsis should be questioned.
See Coding Clinic, fourth quarter 2006, pages 113-116; Coding Clinic,
fourth quarter 2003 page 79; Coding Clinic, fourth quarter 2002, page
f th t 2003, 79 C di Cli i f th t 2002
71; Coding Clinic, second quarter 2000, page 3; Coding Clinic, fourth
quarter 1988, page 10; Coding Clinic, third quarter 1988, page 12; and
Coding Clinic, first quarter 1988, page 1.


49

http://student.ccbcmd.edu/courses/bio141/labmanua/lab12/
diseases/blood/septicemia.html

http://emedicine.medscape.com/article/786058-overview

http://www.fortherecordmag.com/archives/ftr_071204p31.sh
tml

http://hpmp.tmfhqi.net/LinkClick.aspx?fileticket=5vZGv%2Fb
vlos%3D&tabid=521&mid=1247


50


51

Denise Wilson RRT, RN, MIS
Director, Client Education and
Performance Improvement

52

• Understand how to incorporate Best
Practice guidelines in appeals

• Understand how to use regulatory and
CMS guidelines to bolster the appeal
argument

• What to say to an ALJ
y


53

• Considerations for Deciding to Appeal
– Cost
– Time
– Resources
– Chance of Overturn
– Return on Investment
• In addition to:
– Root Cause Analysis
– Education/Remediation Plan


54

• Close examination of decision letter

– What are the instructions for
appeal?
– What forms do I need?
– Where do I send my appeal?
– What was the issue?

• Create Appeal Letter Templates
pp p


55

Building the Foundation


56

CGI Federal RACB Issues
CGI Federal RACB Issues
• http://racb.cgi.com/Issues.aspx

• ICD‐9‐CM Coding Manual (for dates of service on claim)
• ICD‐9‐CM Addendums and coding clinics
• PIM Ch 6.5.3, Section A ‐ C ‐ DRG Validation Review
•
•
Present on Admission Indicator Systems Implementation
OIG Report DRG 416: Septicemia, August 1989 (1)
• OIG Report DRG 416: Septicemia, August 1989 (2)

• Date Approved 12/4/2009
pp / /


57

• Paint the Picture
– Comorbidities and Complications (CC or
MCC)
– Medical Complexity

• P
Provide a Road Map
id R dM
– Where is the Documentation?

• Write to the ALJ
– Best chance of overturn


58

• Use the Best Evidence
– CMS Internet Only Manuals (IOM)
– National Coverage Determinations; Local
Coverage Determinations
– ICD-9-CM Official Coding Guidelines
– C di
Coding Clinics
Cli i
– Code of Federal Regulations (CFR)
– Social Security Act
– Evidence Based Guidelines, Position
Statements, Expert Opinions from National
Medical Associations


59


60


61

• O'Grady NP, et.al., American College of Critical Care Medicine,
Infectious Diseases Society of America. Guidelines for
evaluation of new fever in critically ill adult patients: 2008
update from the American College of Critical Care Medicine
and the Infectious Diseases Society of America. Crit Care
y
Med 2008 Apr;36(4):1330‐49.
• Dellinger RP, et. al., Surviving Sepsis Campaign: International
guidelines for management of severe sepsis and septic shock:
2008. Intensive Care Med 2008 Jan;34(1):17‐60. [341
references]
f ]


62

• Mark Forshag, MD, FCCP. “New Treatments for Sepsis.”
American College of Chest Physicians.
http://www.chestnet.org/education/online/pccu/vol17/lesso
ns15_16/lesson15.php (accessed December 30, 2009).
• Deborah Hale “Coding corner Is it sepsis?” ACP Hospitalist,
Deborah Hale. Coding corner Is it sepsis? ACP Hospitalist
February 2009.
http://www.acphospitalist.org/archives/2009/02/coding.htm
• Gregory A Schmidt, MD, Jess Mandel, MD, Polly E Parsons, MD,
Daniel J Sexton, MD, Kevin C Wilson, MD. “Management of
severe sepsis and septic shock in adults.” (Last updated
October 16, 2009). www.uptodate.com


63

• Gregory A Schmidt, MD, Jess Mandel, MD, Polly E Parsons,
MD, Daniel J Sexton, MD, Kevin C Wilson, MD. “Management
of severe sepsis and septic shock in adults.” (Last updated
October 16, 2009). www.uptodate.com
• Surviving Sepsis Campaign Facts 2009
Surviving Sepsis Campaign Facts, 2009.
http://www.survivingsepsis.org/About_the_Campaign/Page
s/default.aspx. (Accessed December 30, 2009).
• Steven M. Hollenberg, MD, et. Al., “Practice parameters for
hemodynamic support of sepsis in adult patients: 2004
update.” Critical Care Medicine. 2004 September; 32(9):1928‐
1948.


64


65


66


67

42 CFR §§405 900 through 405.1064
§§405.900 405 1064
• ALJ Review Authority
– Jurisdiction
– Scope of Review

• § 405 1062 Applicability of local coverage
405.1062
determinations and other policies not
binding on the ALJ and MAC (Medicare
Appeals Council).
– (a) ALJs and the MAC are not bound by LCDs, LMRPs, or
CMS program guidance, such as program memoranda
and manual instructions, but will g
, give substantial
deference to these policies if they are applicable to a
particular case.


68

20 CFR 416.927: Evaluating Opinion
416 927:
Evidence
• Examining Relationship
• Treatment Relationship
– Length and Frequency
g q y
– Nature and Extent
• Supportability
– Objective and Subjective Findings
• Medical Signs and Laboratory Results


69

• Include an Attachments List

• Include all Attachments
– Electronic Copy

• Use a Document Editor to Highlight the
Medical Record

• Send all Communication via a Traceable
Method


70


71

Healthcare, Inc

Next Session:
Wednesday, June 23
1:00PM EST

Respiratory Failure
with Ventilator Support

For more information or to view upcoming Webinar events,
visit Intersecthealthcare.com

72

Septicemia/Sepsis Slides

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