RSSAuthor Archive for Robert S. Gold MD

Robert S. Gold MD

Dr. Robert S. Gold founded DCBA, Inc., in Atlanta, a consulting firm that provides physician-to-physician programs in CDI. The goals are data accuracy, profile management, and compliance in the inpatient and outpatient arenas. He can be reached by phone at 770/216-9691 or by e-mail at

Look for underlying infection, organ failure, when clarifying sepsis-related conditions

Don't get sick attempting to clarify sepsis

Don’t get sick attempting to clarify sepsis

In 2004, the Coordination and Maintenance Committee created a definition of sepsis that became the basis of ICD-9-CM’s Official Guidelines for Coding and Reporting and was used in a number of AHA’s Coding Clinics. That definition included the supposition that Systemic inflammatory response syndrome (SIRS) plus infection equals sepsis. But that was misunderstood by readers and is only valuable for patients who are critically ill.

In August 2012, the Surviving Sepsis Campaign developed more specifics about which pressors to use in septic shock, the limitations of stress steroids, and the mechanics of ventilator use with acute respiratory distress syndrome (ARDS). In addition, the Surviving Sepsis Campaign paid a lot of attention to the pediatric patients with recommendations about the use of sepsis definitions for children, which had not been previously identified appropriately.

Clinical presentations can vary depending on the original site of the infection, but can also be nonspecific. You can have sepsis, and you know that the patient has sepsis, but you may never find the infection of origin. Or you may have systemic inflammatory response without sepsis because it’s due to something else.

Common symptoms of the body’s systemic response to inflammation include:

  • Fever or hypothermia
  • Tachycardia
  • Tachypnea
  • Elevated or low white blood cell count

These are only symptoms, only lab abnormalities, unless it is determined that their presence is due to the body’s response to an infectious or noninfectious source of inflammation.

Increased efforts by CDI specialists in part led to  physicians documenting SIRS  even when the workup showed that the patient’s tachycardia was due to atrial fibrillation or rapid ventricular response, and the leukocytosis was due to some steroid injections, and the patient didn’t have the systemic response to an inflammatory process at all.

Physicians don’t always document organ dysfunction well, which can cause problems for coders. In order to code severe sepsis, coders need documentation of organ failure. They also need to know the underlying infection.

Editor’s Note: This article was adapted from “Clinical information, queries help reduce confusion when coding sepsis,” published in

Video series highlights CDI opportunities, ICD-10 concerns

DCBA started working with Atlanta Idea Studio marketing firm back in 2012. When they proposed we create educational content via video the entire DCBA team thought that would be a great approach to CDI education, as well as being a little entertaining. The project turned out fantastic and we are all excited and proud of our new video series. So far I have discussed topics like stroke and acute myocardial infarction and plans are in place to create additional videos discussing many more topics.

The regular segments on DCBAtv include “ICD-10 Insights” and “Ask DCBA.”  In “ICD-10 Insights” we give an example of the specificity that is required for ICD-10.  The “Ask DCBA” segment is inspired by our CDI forum  We encourage CDItalk members to ask questions and we illustrate our responses through video.  There is a lot of work that goes into these productions so we hope the CDI community enjoys them. Let us know what you think!

Review clinical picture prior to querying for altered mental status

Confused about querying for altered mental status?

Determining when to seek clarification regarding patients with altered mental status can be tricky business. Patients who already have established dementia and are now off their baseline with an acute metabolic disorder such as UTI, physicians are typically good at documenting that fact. They also indicate when a family member indicates the patient’s behavior is different than normal or when the nursing home staff member indicates the patient’s mental status has changed.

CDI specialists, however, often have a difficult time determining whether the physician means to document a condition due to dementia or whether the patient’s confusion is due to an additional condition such as encephalophy on top of dementia.

It can be difficult for someone without first-hand experience with patients with senile dementia or Alzheimer’s disease or other degenerative brain disorder to visualize the variances that these folks have day-to-day and situation-to-situation. Whether this pertains to a member of your family or whether dealing with patients in a hospital or other care facility and trying to describe this in a note can be challenging, but I’ll give it a go.

Patients with many degenerative brain disorders respond with delirium, or withdrawal, or sleepiness (lethargy), to any change in their environment. Move a patient from a location where he feels comfortable to a different location that isn’t familiar, he can withdraw or get delirious. Furthermore, if they get a little dehydrated, they seem less responsive. Give them a glass of water (or a bolus of 500 ml of saline), they may perk up. It’s all part of the basic condition.

A true encephalopathy (the intent of ICD-9-CM codes in the 348 grouping) is to describe a toxic condition with the potential of causing permanent harm to the brain. These include many of the metabolic encephalopathies as exist in hepatic encephalopathy with ammonia running around, hypercalcemic encephalopathy with calcium in the 12 range, and metabolic encephalopathy that can occur with sepsis.

Metabolic encephalopathy due to a septic condition requires documentation of more than a slight alteration of consciousness as the patient with septic encephalopathy is already not perfusing the kidneys and other body organs. Look for elevations of creatinine (which may not yet be acute kidney injury) or the look for documentation about whether patient is breathing weird (may not yet be acute respiratory failure). These indicators reflect the fact that the patient is awfully sick. If that patient perks up after a little saline, it wasn’t septic encephalopathy. If it takes a couple of days of high powered antibiotics, maybe it was.

The other encephalopathies (toxicity to long term alcohol exposure, poisonings, Lyme encephalopathy, transmissible spongiform encephalopathy or Mad Cow disease, etc.) don’t apply to this case, so I won’t go into them.

Basically, CDI specialists should determine the patient’s response to initial treatment and the overall clinical picture of how sick the patient is before asking the physician about altered mental status. Maybe it was just Sun-downing Syndrome.

Editor’s Note: ACDIS Advisory Board member Robert S. Gold, MD, is founder and CEO of DCBA, Inc., in Atlanta. Contact him at

Physicians: Use your continued clinical judgement when determining diagnoses

When should you document acute blood loss anemia? Use your clinical judgement and review all relevant indicators.

Physicians in the ED setting must make observations and determinations rapidly. Differential diagnoses often precede hospital admission. Sometimes all you have are symptoms, but you know the patient is very sick. Sometimes you know exactly what that sickness is. Sometimes a lab result will lead you down a path of diagnostic tests and treatment modalities that, after study, weren’t so necessary or were just wrong.

Keep some of these issues in mind, whether in the ED or on the medical-surgical units, when you document your ongoing evaluation of patients.

In the remainder of this article we will discuss some familiar concerns and possible alternatives.

Potassium levels in the range of seven or so (you know to look for the possibility of hemolysis before administering glucose, insulin, and Kayexelate). Blood pressure of 60/40 in a patient who just looks too healthy (you know to repeat the blood pressure on the opposite arm before starting boluses and pressors). These don’t represent hyperkalemia and shock. They’re abnormalities.

Is a creatinine of 3.4 acute kidney injury (AKI)? A patient may come into the hospital with signs of severe illness. On the initial workup that would likely include a complete blood count with differential and complete metabolic panel, you might find a significantly elevated creatinine. If the patient’s condition looks like it could be associated with renal damage, you might initially call this AKI or acute renal failure. And depending on the perceived mechanism, whether consistent with a prerenal, intrarenal, or postobstructive condition, you’ll institute appropriate therapy.

However, when you know—from previous encounters with this patient or after the institution of treatment—that the creatinine level is high but hasn’t moved, the problem could be an elevated creatinine related to chronic kidney disease (CKD). You should confirm in the progress notes that what was originally thought to be AKI on admission turned out to be CKD stage 3 due to the patient’s diabetic nephropathy, or whatever mechanism you concluded caused the problem.

Is a B-type natriuretic peptide (BNP) of 5,600 indicative of a patient with acute congestive heart failure (CHF)? A patient may be admitted with shortness of breath, either new or worse than before. The chest film may be interpreted as having cardiomegaly and maybe even pulmonary vascular congestion. And your response to this, in view of a BNP of 5,600, might be to administer a diuretic. Well, many of these cases turn out to be nothing other than acute CHF; however patients with end-stage CHF with significant systolic dysfunction and ejection fractions in the range of 15%–25% may very well walk around normally with a BNP of 5,600—or even considerably higher! And the shortness of breath may really represent a cold, sinusitis, or pneumonia.

Be wary of the end- stage renal disease (ESRD) patient or the patient with cor pulmonale who is volume overloaded in the best of times. Once it is recognized that the patient has another reason for the elevated BNP level, be sure to document the following: What was the diagnosis initially thought to be? Acute diastolic heart failure on admission may turn out to be a reflection of the patient’s end-stage heart (or renal) disease.

Does an albumin of 1.6 always reflect ‘severe malnutrition’? Not on your life, although some people at your hospital may want you to document “severe malnutrition” based on a single determination of serum albumin. Say the patient has a long-standing protein losing enteropathy or nephropathy or is in severe eclampsia. Further, the patient has an albumin level of 1.6 while playing intramural or interoffice sports. No way does the patient have “severe malnutrition.”

Is a hemoglobin of 9.8 after surgery ‘acute blood loss anemia’? Don’t fall into the trap. If the patient started with a hemoglobin of 9.7 because of end-stage renal disease, sickle-cell disease, chronic hepatitis, or chronic blood loss from the cecal cancer on which doctors operated, forget it! The anemia existed prior to admission. Perhaps a patient goes into surgery with a hemoglobin of 12. Because of the patient’s diabetic peripheral neuropathy, he requires 2.5 liters of crystalloid to maintain blood pressure perioperatively. The estimated blood loss in the case is 50 cc. Is there a chance the hemoglobin drop was purely dilutional? Don’t respond automatically with “acute blood loss anemia” when evidence shows that there was another specific cause. And don’t respond you know it wasn’t anemia due to acute blood loss.

Is an elevated troponin an acute myocardial infarction (MI)? A patient may appear in the ER or in your office with crushing chest pain or weakness and diaphoresis and maybe an irregular heart rhythm. An EKG shows no acute ST wave changes or deep Q waves, but the troponin level comes back as 0.4 with the lab’s high normal at 0.03. Is that a non-ST elevation MI? Could be! While you’re thinking about administering aspirin and working the patient up for the possibility of sending him or her on to the cath lab, take a look at several options. Is it an MI? Is it a non-ST elevation MI caused by a demand issue as might happen with shock or severe anemia or hypertensive emergency? Is it an MI caused by arteritis or coronary artery spasm or Kawasaki disease? Or does the patient have a massively enlarged heart, whether dilated or hypertrophied, with ongoing compromise of the myocardium; in this case you’ll likely find that the subsequent troponin levels were the same as the admission level and an acute MI did not occur. Does the patient have ESRD and a consistently elevated troponin level? In these instances, be sure to clarify in your notes that a MI probably did not occur.

In all of these instances, “copy and paste” day after day with the same diagnoses that never change and show no complexity of medical decision-making. However, be sure to clarify when you know that something that was considered on admission was ruled out!

Editor’s Note: Dr. Gold founded DCBA, Inc., in Atlanta, a consulting firm that provides physician-to-physician programs in clinical documentation improvement (CDI) and training of CDI specialists to support the needs of the medical staff. Contact him by phone at 770-216-9691 or by email at

This article originally published in the July 2012 edition of Medical Records Briefings. Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions.

Respiratory failure code description limitations and documentation requirements

Capture appropriate documentation for respiratory failure.

In March 2011, the ICD-9-CM Coordination and Maintenance Committee updated the following code definitions and exclusions:

  • 518.5: Pulmonary insufficiency following trauma and surgery
  • 518.51: Acute respiratory failure following trauma and surgery
    • Respiratory failure, not otherwise specified, following trauma and surgery
  • 518.52: Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery
    • Adult respiratory distress syndrome (ARDS)
    • Pulmonary insufficiency following surgery
    • Pulmonary insufficiency following trauma
    • Shock lung related to trauma and surgery
  • 518.53: Acute and chronic respiratory failure following trauma and surgery
    • Excludes: acute and chronic respiratory failure in other conditions (518.84)
  • 518.8: Other diseases of lung
  • 518.81: Acute respiratory failure
    • Excludes: acute respiratory failure following trauma and surgery (518.51)
  • 518.82: Other pulmonary insufficiency, not elsewhere classified
    • Excludes: acute interstitial pneumonitis (516.33) ARDS associated with trauma or surgery (518.52) pulmonary insufficiency following trauma or surgery (518.52)
  • 518.84: Acute and chronic respiratory failure
    • Excludes: acute and chronic respiratory failure following trauma

I’d like to discuss some of the limitations and challenges of these codes and their current descriptions.

Postoperative and post-traumatic respiratory failure

ICD-9-CM codes 518.5–518.53 include the description “following trauma and surgery.” Combining trauma and surgery into one code is inappropriate. Patients with trauma, lung contusion, or bilateral traumatic pneumothoraces or hemothoraces will develop post-traumatic respiratory failure. The same is true for patients with crushed tracheas. These patients are distinctly different from those with postoperative respiratory failure. Each group should be tracked differently; therefore, they should be coded differently too.

Research is impeded by not coding and tracking each group separately. That’s because even when a patient experiences trauma, surgery may be the actual cause of the postoperative respiratory failure. The POA indicator does not help clarify the cause of post-traumatic respiratory failure because respiratory failure may or may not exist on admission. [more]

Cardiomyopathy: A Valentine’s Day documentation reminder

Happy Valentine's Day from ACDIS

Editor’s Note: Have a little extra thrum in your heart due to the trappings of the day? We did. So we’ve picked up this piece written by ACDIS Advisory Board members Robert S. Gold, MD, originally published in the December 2011 edition of our sister publication Briefings on Coding Compliance Strategies.

Cardiomyopathy (CMP), a disease that affects the heart muscle, is frequently misreported. When cardiologists document the term “CMP,” it usually denotes their awareness that the patient has a sick heart. They may evaluate the heart as being dilated and as having a low ejection fraction. However, they don’t always evaluate pathophysiology. Without this evaluation, documentation of CMP can be deceiving. When coders see this documentation, they report ICD-9-CM code 425.4 for the CMP even when the patient may have something else.

A quick Google search yields a variety of causes of cardiomyopathy. There are specific ICD-9-CM codes in the 425 code series for each type of cardiomyopathy. For example:

  • Codes 425.11 and 425.18 denote idiopathic hypertrophic cardiomyopathy with or without obstruction, respectively.
  • Code 425.5 denotes alcoholic cardiomyopathy.
  • Code 425.7 denotes nutritional cardiomyopathies, such as due to amyloidosis and beriberi. Some very rare cardiomyopathies are also specifically named in this section. Two examples are endocardial fibroelastosis (code 425.3) and obscure cardiomyopathy of Africa (code 425.2).
  • Code 425.8 denotes other specified cardiomyopathies in diseases classified elsewhere that can also affect the heart muscle and its function. These include Friedreich’s ataxia, progressive muscular dystrophy, sarcoidosis, and myotonia atrophica.

Other specific causes of cardiomyopathy are not included in the 425 code series.

If you look for hypertensive cardiomyopathy in the Alphabetic Index of the ICD-9-CM manual, it leads you to hypertension with cardiac involvement. This leads you to the 402–404 code series.

Hypertensive cardiomyopathy is a type of cardiomyopathy; however, it doesn’t exist in the 425 code series. Coding Clinic, Second Quarter 1993, p. 9, instructs coders to assign both the 402 (or 404) series code and code 425.8 to designate cardiomyopathy in diseases classified elsewhere.

Similarly, ischemic cardiomyopathy (code 414.8) is not listed under cardiomyopathy even though it is a cause of heart disease that can lead to dysfunction. No advice exists for the addition of code 425.8 even though it is among the most frequent causes of cardiomyopathy in the United States. This represents an error in the coding system. ICD-9-CM code 414.8 denotes ischemic heart disease just as codes 403 and 404 denote hypertensive heart disease. They each require code 425.8 to capture the complete description of the condition.

Several Coding Clinic references cite code 425.4 (other primary cardiomyopathies) for cardiomyopathy. These references state that coders should report this code for cardiomyopathy that includes such terms as “congestive,” “constrictive,” “familial,” “idiopathic,” “restrictive,” or “obstructive.” However, these references are incorrect. Code 425.4 should be used only for primary cardiomyopathies not otherwise specified or when physicians document one of the aforementioned nonessential modifiers.

When a patient has cardiomyopathy that is secondary to another condition—and the cause is unknown—coders should report code 425.9 (secondary cardiomyopathy, unspecified). When the cause is known, they should report code 425.8. These codes (i.e., 425.8 and 425.9) should be used when documentation includes any one of the nonessential modifiers listed under code 425.4 and when the cardiomyopathy is due to another condition.

The term “idiopathic” means that the physician cannot determine the cause of the cardiomyopathy despite extensive workup. If the physician can determine the cause, then by definition it’s secondary cardiomyopathy.
Ischemic heart disease is a disease classified elsewhere. Similarly, hypertension is a disease classified elsewhere. Therefore, code 425.8 should be added to 414.8 (other specified forms of chronic ischemic heart disease) for ischemic cardiomyopathy.

Pediatric reviews: Know the rules before you play the game

by Robert S. Gold, MD

Even experienced and consistently accurate acute care hospital coders may not be familiar with pediatric

Don't throw the baby out with the proverbial bathwater when it comes to documentation and coding improvement associated with pediatrics.

diseases. Age is not a factor for some conditions (e.g., appendicitis). Others are age-specific or have age-specific diagnosis, healing, and treatment implications. Coders must consider this when assigning codes and querying physicians.

Consider a Colles’ fracture. It occurs in both children and adults, but the healing process is different because of the growth plates in the pediatric population. Aspiration pneumonia can present in both groups, but the cause may differ anatomically and microbiologically. Bronchospasm in adults likely has a completely different cause than in children. Diabetes may have similar long-term outcomes, but type 1diabetes is more difficult to manage psychosocially than type 2 in the pediatric population.

Numerous examples illustrate the differences between pediatric and adult diseases. Bacterial causes of pneumonia differ based on age group. Cerebral hemorrhage may have the same fatal outcome in children and adults, but rarely the same cause. Physicians must approach causes of respiratory distress in children quite differently. Heart failure is completely different in the two groups. Even the types of cancers that occur in children are different.


What severity-adjusted payments mean for documentation improvement

Editor’s Note: Ready to take a trip in your way-back machine? I was scanning through articles on when I came across

The journal Medical Records Briefing celebrates its 25th anniversary this year.

this article from the November 2006 edition of Medical Records Briefing which is celebrating its 25th anniversary this year.

In the article Robert S. Gold, MD, discusses the dawning of a new day in Medicare reimbursement—Severity-Adjusted Diagnosis Related Grouping (DRGs). No doubt seasoned CDI professionals will recognize some familiar themes in his now five-year-old piece.

For example, Gold states, “if physicians have been doing it right up until now, they won’t have to change how they validate their billing and the levels to which they are entitled.” Haven’t CDI specialists and the HIM department been saying the same thing in regard to the switch from ICD-9 to ICD-10? Haven’t CDI specialists and the HIM department been saying the same thing about the coming shift to “value-based purchasing”?

And Gold offers a tongue-in-cheek early assessment of CDI programs calling them “so-called documentation improvement” programs, pointing to the early implementation efforts which focused primarily on capturing additional CCs and MCCs and increasing the relative weights for which a facility could bill the government. Then our beloved soon-to-be ACDIS Advisory Board member touts what he believes are better goals for the then-fledgling CDI profession.

Without further ado, enjoy.

By Robert S. Gold, MD

First, the good news: something reasonable is happening in Medicare-severity-adjusted payments. It started last year for hospitals, will increase this year, and will be pervasive next year. Medicare has been practicing for severity-adjusted payments for the past two to three years with physicians and, undoubtedly, will roll it out to physician payments in the near future. Between that initiative and pay-for-performance, a lot of change is in the future.

But if physicians have been doing it right up until now, they won’t have to change how they validate their billing and the levels to which they are entitled. Unfortunately, most hospitals around the country are going to go wild, starting new initiatives for “documentation improvement” in order to validate their increased (or sustained) revenues.

Hospital billing, which has been the driving force for the myriad of so-called “documentation” programs, has for years had the wrong outlook. Hospitals have been seeking a higher paying DRG. And members of the medical staff have had the right outlook-that, traditionally, it’s just been for the hospital. Unless the program has been designed for accurate representation of what is totally wrong with the patient to drive accurate and specific code assignments. And there have been few of these programs out there.

A true “clinical documentation improvement” program is something directed toward leadership by the medical staff, not something aimed at the medical staff. It helps the physicians provide documentation in the medical record that will:

  • convert easily into ICD-9-CM codes that will describe what’s wrong with their patients
  • demonstrate severity of illness and risk of mortality
  • provide the medical necessity that utilization nurses are so passionate about
  • validate quality of care as well as professional billing through CPT codes

What do the changes mean?

Starting last year with cardiovascular conditions and extending this year to gastrointestinal disorders and some changes in neurology and urology, hospitals will receive severity-adjusted payments. A bunch of new DRGs have been created that differentiate payment levels based on the presence or absence of these severity issues.

Some will be based on diagnoses, some on procedures. But hospitals that don’t know how to deal with this change will be scrambling to bug the physicians for changes in documentation practices so that they can bill at a higher level. Hospitals that have been doing it right until now won’t have to change anything.

Well, folks are planning to deal with MS-DRGs the same way that they did with the original DRG system.  That didn’t work then and it won’t work now.  It’s not only what will affect the MS-DRG assignment that ultimately makes the difference.  It’s the identification of all clinical entities that affect the health of the patient that counts.  It’s the patient that matters, not the hospital finances.  Finances will follow logically.”

From my perspective, the physicians and staff who deal with patients everyday need to have the support they require to make it easier, not harder to document properly so that everybody’s needs are met: especially, the patients. The physicians need facilitation, not roadblocks. They need helpers, not interferers. They need education, not rebuke, such as: “Get your patient out of the hospital,” or “Write ‘Cannot rule out aspiration pneumonia’ on the chart.'”

There have been some changes in the past few years such as reporting of mortality rates, utilization profiles, and cooperation with quality initiatives at the hospital. These may not be what you want to see in the environment of medical practice, but they are a reality. Medical staff can ignore them, certainly, but they won’t go away.

Well, public reporting of mortality and morbidity is there. Financial profiles are there.  And the next step, which can only be helped if providers participate in a true documentation improvement initiative, is going to be variable payments for physician billing based on severity of illness and pay for performance.

Should providers learn the new MS-DRG coding system?

No. But it couldn’t hurt. At least be aware of what makes a difference. Let’s look into a few examples of what makes quality documentation and what doesn’t.

ICD is a system of sorting diseases by pathogenesis so that you can tell what kills patients. As there are many different causes of an outcome, ICD has specific code sets for many of them and, in the absence of a specific cause documented, will default to the most commonly occurring in the world (not just in the Medicare population in the U.S.).

If a provider documents that a patient has Charcot foot and are not specific as to the cause, it will default to “due to tertiary syphilis.” If a provider states that it was due to diabetes with autonomic neuropathy, syringomyelia, or whatever the cause was, coders will assign specific codes.

If a provider documents that a patient has cardiomyopathy because it’s easy to write down three letters, and he or she doesn’t specify what is causing the sick myocardium, it defaults to congenital, the number one cause in the world—not in the Medicare population in the U.S. And what are the chances that this properly represents the patient?

Every diagnostic entity that a provider treats and works up, needs documentation of the symptoms (in the outpatient arena) or the diagnosis (when you have determined that in the inpatient arena), and it should be as accurate and specific as possible. Someone in the office or hospital has to know that there are specific codes for specific situations and, if the provider supplies the words that make the difference, the codes, severity of illness, utilization review, and documented quality will take care of themselves.

Whether a provider is in a DRG environment, a severity-adjusted environment, a fee-for-service environment, a per diem one, or dealing with ICD-9 or the upcoming ICD-10, if he or she thinks that way, they’re there already and won’t have to change anything.

If a hospital is helping its providers get there, they’re okay. If a hospital has been directed toward “what’s in it for them,” then providers will need help. It’s a shame that so many folks have been misdirected so long. And it’s a shame that the people in the medical schools didn’t recognize decades ago that this was coming and prepare us all with standardized nomenclature that meets the needs of the ICD.

Editor’s note: Dr. Gold founded DCBA, Inc., in Atlanta, a consulting firm that provides physician-to-physician programs in clinical documentation improvement. The goals are data accuracy, profile management, and compliance, either in the inpatient or outpatient arenas. He can be reached by phone at 770/216-9691 or by e-mail at

This article was excerpted from the November issue of Medical Records Briefing.

Query questions: When should you not query?

I recently attended the annual meeting of the ACDIS in Orlando where I heard a variety of perspectives during many informative

CDI specialists enjoy the pre-summer air during the 2011 ACDIS Awards Luncheon.


A common thread in many discussions was how to query physicians using information in the medical record and when it’s appropriate to do so. Coders and CDI specialists must remember that a valid diagnosis must be supported by evidence in the body of the medical record. What does this mean?

Let’s consider the often difficult decisions associated with three common diagnoses: Anemia, acute renal failure, and sepsis.


Q&A: Querying for SIRS when clinical indicators are present

Seems there's no end to questions about the difference between SIRS and sepsis. Here's a brief reminder from Dr. Gold.

Q: Is systemic inflammatory response syndrome (SIRS) an inherent part of an infection? For example, when a patient comes in with pneumonia, and clinical indicators are present for SIRS but the physician did not specifically write SIRS, should coders or CDI specialists query physicians?

A: SIRS is a response by the body to dead or injured cells. It is inherent in infections and should not be sought after when the condition is an obvious infection. Pneumonia, for example, is an obvious infection.

Certain advice from coding authorities has CDI specialists/coders to lead physicians down the garden path of identifying and documenting SIRS whenever a patient has two of the four criteria described in the Journal of Critical Care Medicine. However, the criteria for SIRS referenced in the article were actually established in 1992 as part of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. The conference concluded that the manifestations of SIRS include, but are not limited to:

  • Body temperature less than 36°C or greater than 38°C
  • Heart rate greater than 90 beats per minute
  • Tachypnea (i.e., high respiratory rate) with greater than 20 breaths per minute and/or an arterial partial pressure of carbon dioxide less than 4.3 kPa (32 mmHg)
  • White blood cell count less than 4000 cells/mm3 (4 x 109 cells/L) or greater than 12,000 cells/mm3 (12 x 109 cells/L), and/or or the presence of greater than 10% immature neutrophils (band forms)

But soon CDI specialists/coders started to query physicians about SIRS when only a couple of the aforementioned criteria were present regardless of how sick the patient was and regardless of whether vital sign changes were even related to the identified infectious process.

Overcoding SIRS leads to inappropriate billing, not to mention the potential for RAC recoupments and tremendous penalties if identified by the Office of Inspector General.

When a patient has sepsis (ICD-9-CM code 038.xx), the patient has sepsis.

The 2001criteria for sepsis from the Journal of Critical Care Medicine emphasizes that. It states that the patient has to be truly sick from the infection. If the patient does not have sepsis in the face of an infection, the presence of SIRS is implied.

Virtually all patients with acute appendicitis meet the criteria for SIRS, and it’s only the rarest cases of appendicitis that have sepsis. Most patients with bacterial pneumonia exhibit signs and findings of SIRS, but most receive outpatient treatment and do not have sepsis.

Editor’s Note: This article first appeared on Learn more about the difference between sepsis and SIRS in the following articles: