HIMagine That: New definitions for sepsis and septic shock

April 20, 2016 / By Sue Belley, RHIA, Donna Smith, RHIA

Donna: Sue, have you been reading about the new definitions for sepsis and septic shock, and the new clinical guidance for physicians about diagnosing sepsis in their patients?

Sue: Yes, I have. It’s definitely top of mind for physicians, nurses and other healthcare providers, not to mention coding and CDI professionals.

Donna: I know! I’ve been getting a lot of questions from coding professionals asking if they should change the way they are coding sepsis and CDI professionals are asking if they should be clarifying documentation and querying physicians when reviewing the medical records of septic patients.

Sue: I am fielding a lot of questions too. I think the first thing coders and CDI reviewers need to do is review the new definitions for sepsis and septic shock. Here’s what the guidelines say: “Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection. Septic shock is defined as a subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities substantially increase mortality.”

Donna: Wow, did you memorize that? I’m impressed, Sue! 

Sue: [sigh] Donna, you know that I’m always staring at my computer screen. I’m reading the definitions on the Society for Critical Care Medicine’s website!

Donna: Sorry. 🙂 Did you notice, though, that the term severe sepsis is not defined in these definitions.

Sue: True, and the reason for that is because the task force that came up with this new clinical guidance for diagnosing sepsis stated that the term severe sepsis is redundant because sepsis has a mortality rate of 10 percent or higher which automatically makes this a severe condition. The terms sepsis syndrome and septicemia have also been eliminated.  

Donna: So, you’re not the only one who spends a lot of time in front of a computer screen. I noticed that JAMA recently published an article, which includes a table that correlates the new clinical definitions of sepsis with ICD-10-CM codes. This correlation links codes R65.20 and R65.21 with the definitions for sepsis and septic shock, respectively.

Sue: Yes, the correlation between the new definitions and ICD-10 codes was interesting; however, at the present time we must follow the conventions of ICD-10-CM and the FY 2016 ICD-10-CM Official Guidelines for Coding and Reporting, which direct us to assign the appropriate code for the underlying systemic infection. If type of infection or causal organism is not further specified, code A41.9, Sepsis, unspecified organism, is assigned. A code from subcategory R65.2-, Severe sepsis is not assigned unless severe sepsis or an associated acute organ dysfunction is documented.

Donna: Exactly, and therein lies the rub, as we cannot assign R65.2- unless the physician documents severe sepsis or associated organ system dysfunction. So the question that’s top of mind is should we be querying and if so, for what exactly? Any codes assigned for sepsis and associated conditions must be in sync with the guidelines and conventions, and of course any Coding Clinic advice that may be published.

Sue: My best advice for CDI professionals is that they should work closely with physicians to clarify the clinical guidelines for sepsis in use at their facilities. Make sure that clinical documentation reflects the patient condition so that coding professionals can assign the codes that tell the story.  Coding professionals should continue to follow the official coding guidelines and conventions.

Donna: Yep, I agree.  It will probably take the medical community some time to mobilize and integrate this new clinical guidance into their clinical practice, just like it will take some time for the coding and CDI communities to determine what, if any, coding guidelines and advice may need to be modified to be in sync with clinical practice.

Sue: Stay tuned…I am sure there will be some thought-provoking discussion on this topic as well as others at next week’s 3M Client Experience Summit in Salt Lake City!

Donna: See you there!

Sue Belley, RHIA, and Donna Smith, RHIA, are project managers with the consulting services business of 3M Health Information Systems.