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Q&A: Coding mixed cardiogenic and septic shock

Have CDI questions?

Have CDI questions?

Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?

A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed below there is an Excludes1 note. Remember, Excludes 1 notes instruct us that we cannot use codes from this grouping with those listed within the Excludes 1 note. Cardiogenic shock (R57.2) falls within this grouping. Also listed is R65.2 septic shock. Purely relying on the coding conventions, I would conclude that we cannot code septic shock with cardiogenic shock. See the image below. [more]

Note from ACDIS Director: The changing tide of sepsis definitions

ACDIS Director, Brian Murphy

ACDIS Director, Brian Murphy

By Brian Murphy

These days it seems sepsis is constantly in the news. Hardly a day passes where the efficacy of some new life-saving drug is being advocated or disputed, a sepsis DRG downgraded, or Sepsis-2 versus Sepsis-3 definitions debated. We’ve also had some major recent news from the likes of the Surviving Sepsis Campaign.

CDI specialists inhabit a world in which they need to navigate three sets of reporting requirements: Sepsis-2, Sepsis-3, and SEP-1, the latter from the National Quality Forum measure for public reporting of sepsis.

How can CDI specialists make sense of it all? I recommend reading our most recent ACDIS White Paper, “Where are we now with sepsis?”

The paper covers in detail the multiple issues around this tricky diagnosis, from the problems inherent in administrative versus clinical data, to systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock prior to the new Sepsis-3 definitions in 2016, and the definitions post Sepsis-3. The article also includes a nice bulleted summary and takeaways for your CDI department and medical staff.

Special thanks for principal authorship go to ACDIS advisory board member Sam Antonios, MD, FACP, SFHM, CPE, CCDS. Though primary authorship goes to Antonios, the entire ACDIS advisory board reviewed the work prior to publication.

To download the new White Paper, click here.

I would also encourage any of our ACDIS members who haven’t been by our resource pages in a while to check out all our White Papers and Position Papers. We’ve been publishing some helpful guidance of late, and more is on the way.

I hope this paper proves helpful in your continued mission of clinical accuracy in the patient chart.

If you have suggestions for topics you’d like to see the advisory board address, please let me know via email at

Breaking News: The Surviving Sepsis Campaign releases new guidelines for Management of Sepsis and Septic Shock, 2017

Allen Frady

Allen Frady

By Allen Frady, RN, BSN, CCDS, CCS

Management and practice guidelines are not often at the forefront of CDI focus and training. As quality and revenue reviewers, we more often find ourselves involved in clinical definitions and criteria, as we simply try to determine if a diagnosis exists.

As clinical validation and audit activities push CDI specialists closer to denial defense efforts, we must also be aware of the most current recommendations with regards to treatment. Last week in the both Journal of American Medical Association (JAMA), and a number of critical care publications such as the Society of Critical Care Medicine, we got our first peek at newly updated treatment recommendations coming out of the Surviving Sepsis Campaign. Although these publications represent more of an evolutionary update (compared the revolutionary change of definition we saw with last year’s release of Sepsis-3 definition changes) there are some noteworthy talking points here for CDI specialist.

The publication takes a rather comprehensive approach, covering every possible facet of monitoring and treating patients in sepsis (that is, after all, part of the Surviving Sepsis Campaign’s mission). Starting with the initial resuscitation, the update includes a shortening of the initial time for the early directed therapy treatments (for some components such as administering IV fluids) from six hours to three hours.

Monitoring suggestions have also gotten more specific, changing from general parameters for urinary output, mean arterial pressure, and invasive cardiac monitoring to a recommendation of frequent perfusion reassessment and adjustment made on an increased number of data points and focusing on dynamic parameters rather than static ones. The specific IV fluid recuitation recommendation is now 30ml/lg of crystalloid fluids over three hours (assuming stable renal and cardiac function of course).

Reassessment now includes an evaluation of everything from heart rate, to general blood pressure, arterial oxygen saturation, respiratory rate, with the continued recommendation of maintain the map of at least 65 or greater and introducing invasive monitoring for central venous pressure etc. in patients who are in critical status.

It makes further recommendations using lactate levels as part of the ongoing data to measure the amount and effectiveness of necessary fluid therapy.

Studies show that facilities who establish comprehensive sepsis protocols and performance standards have better outcomes. Doing so has become a recommendation across the board. If possible, patients should get blood cultures before starting antibiotic therapy as long as it does not delay antimicrobial administration any significant length of time. Another recommendation is to immediately test for and repeat monitor lactate levels.

The guidelines go on to address the specific antimicrobial selections, vasopressor escalation, source identification and recommendations for things like blood transfusion, anticoagulant administration, use of mechanical ventilation, management of ARDS patients, DVT prophylaxis, nutritional support and use of corticosteroids.

There new guidelines contain a vast amount of treatment information (too much to detail here) but as I mentioned, the recommendations are evolutionary in nature, not revolutionary.  I have been teaching CDS the 30ml/kg guideline along with the importance of lactate and procalcitonin for a few years now.  It is nice to see it in the practice guidelines.

One noteworthy point I want to mention, is the subject of de-escalation of therapy. In some cases, auditors will use a change or drop in antibiotics or a decrease in IV fluid administration as evidence that sepsis was ruled out. Nothing could be further from the truth. One of the reasons they suggest that blood cultures and wound cultures be performed early is so that they can appropriately de-escalate antimicrobial therapy in light of possible findings of the organism. In the era of increasing antimicrobial resistance with the over prescription of antibiotics, and in a critical care scenario when certain antibiotics may be nephrotoxic or hepatotoxic, this is likely to be more a sign of responsible stewardship than an indicator of diagnostic value.

The Surviving Sepsis Campaign specifically mentions the following recommendations:

  • De-escalation to the narrowest effective antimicrobial agent for most serious infections.
  • A thoughtful de-escalation of antimicrobials based on adequate clinical improvement in spite of the possible initial culture findings.
  • De-escalation with discontinuation of combination therapy within the first few days in response to clinical improvement or evidence of infection resolution in septic shock patients.
  • De-escalation of early multidrug therapy is associated with equivalent or superior clinical outcomes in sepsis and septic shock in some observational studies. This one needs more study however.
  • They recommend, daily assessment for de-escalation of antimicrobial therapy in patients with both sepsis and septic shock.
  • Various procalcitonin-based algorithms have been used to direct de-escalation of antimicrobial therapy in severe infections and sepsis. This also needs further study however. In total, the phrase “de-escalation” appears in the article no less than 30 times.

The next time you hear someone argue that a decreasing of vasopressors, IV fluid, or antimicrobial therapy proves there was no sepsis or shock, remind yourself that this has largely been debunked. De-escalation is in fact, a responsible part of sepsis management. Not every patient’s presentation would merit early de-escalation of course.

If physicians are abruptly stopping (not de-escalating) therapy such as antibiotics and or IV fluid and monitoring early in the episode, that could be a sign that either the sepsis was in fact ruled out, or could be that the early goal directed therapy worked exceptionally well. In such a case, a query is in order to ascertain the proper physician documentation that the sepsis was either ruled out, or was an atypical case which resolved early.

The goals here are clearly stated by the Surviving Sepsis Sampaign however—that antibiotic therapy should if at all possible, start being reduced within about three days if the patient is responding well to treatment. What you would likely see here is a change from multi therapy to a single IV antibiotic. In some cases, with antibiotics which have good PO absorption in a patient with no GI pathology, a change to PO antibiotics is possible. In other cases, antibiotics might be discontinued entirely. This is not evidence that there was no sepsis. The same goes for the fluid therapy. These practice reference repeatedly describe the time period as a “few” days. For most people “few” means around three. They further mention an early therapeutic window of only three to five days. Some studies in fact are cited in this paper which show that the shorter treatment periods of three to five days can be just as effective as seven and 10-day treatment protocols. These shorter treatment windows have also been associated with improved outcomes in some studies.

As more and more education and pressure is put on physicians about the dangers of antimicrobial resistance, and as we analyze the impacts long term to the kidneys and liver of hard to metabolize antibiotic therapy and as we see the impacts of over treating patients with antibiotics actually leading to increased readmissions due to the extinguishment of the natural healthy flora and the breeding of resistant organisms, we are likely going to see a trend towards these shorter treatment periods as standard sepsis care.

Link to Abstract:

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at For information regarding CDI Boot Camps visit

Guest Post (Part 4): Finding coding compliance at a crossroads

James S. Kennedy

James S. Kennedy

Note: This post is part four of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.

by James S. Kennedy, MD, CCS, CDIP

In earlier posts, we discussed the evolution of the definition of sepsis and its implications in clinical care (Sepsis-1, Sepsis-2, and Sepsis-3), quality measurement (CMS’s SEP-1 core measure), and ICD-10-CM coding compliance.

We emphasized that the February 2016 definition of sepsis (Sepsis-3) as a “life-threatening organ dysfunction caused by a dysregulated host response to infection,” differed from the terminology of sepsis and severe sepsis that has been embraced by many clinicians, CMS, and ICD-10-CM. We also discussed how provider documentation using the Sepsis-3 terminology eliminates the term “severe sepsis,” and discussed that the definition change affected ICD-10-CM code assignment and compliance.

(Definitions and clinical indicators in Sepsis-2 are available here, and definitions for Sepsis-3 are available here. CMS’s definition of sepsis and severe sepsis for the SEP-1 core measure is available here. Please familiarize yourselves with these differing definitions.)

Coding Clinic update

Effective September 23, the American Hospital Association (AHA) Coding Clinic for ICD-10-CM/PCS published advice concerning the documentation and coding of sepsis in light of Sepsis-3. In Coding Clinic, Third Quarter 2016, p. 8, they stated “coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone. Code assignment should be based strictly on physician documentation (regardless of the clinical criteria the physician used to arrive at that diagnosis).”

Coding Clinic went on to write (emphasis mine):

The coding guidelines are based on the classification as it exists today. Therefore, continue to code sepsis, severe sepsis, and septic shock using the most current version of the ICD-10-CM classification and the ICD-10-CM Official Guidelines for Coding and Reporting, not clinical criteria.

In my opinion, this means that if the diagnosis is incorporated by the documenting physician, Coding Clinic is saying ICD-10-CM still embraces the coding of:

  • infections without sepsis
  • with sepsis but without organ dysfunction
  • with sepsis resulting in organ dysfunctions (otherwise known as severe sepsis)

The AHA further stated that if a physician arrives at a diagnosis of sepsis or severe sepsis using whatever criteria he or she wishes, and then documents these terms in the medical record, the coder is to code it, period, end of story.

Alternatively, while Sepsis-3 states that the word “sepsis” requires the presence of acute organ dysfunction, Coding Clinic states that ICD-10-CM does not recognize this clinical concept. Unless the provider documents “severe sepsis” or associates an acute organ dysfunction to sepsis, a code reflecting this concept, R65.20 (severe sepsis), cannot be assigned. Furthermore, if a provider wishes to diagnose and document the term “sepsis” (without organ dysfunction) using Sepsis-2 or other reasonable criteria, the coder is obligated to code it as such in ICD-10-CM.

Coding Clinic, Fourth Quarter 2016          

As we discussed in previous ACDIS Blog posts, the fiscal year 2017 ICD-10-CM Official Guidelines were amended to state (emphasis mine):

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

In explaining this new guideline, Coding Clinic, Fourth Quarter 2016, pp. 147-149 stated (emphasis mine):

While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria. In other words, regardless of whether a physician uses the new clinical criteria for sepsis, the old criteria, his personal clinical judgment, or something else to decide a patient has sepsis (and document it as such), the code for sepsis is the same—as long as sepsis is documented, regardless of how the diagnosis was arrived at, the code for sepsis can be assigned. Coders should not be disregarding physician documentation and deciding on their own, based on clinical criteria, abnormal test results, etc., whether or not a condition should be coded.

Coding Clinic went on to highlight that this concept applies only to coding, not the clinical validation that occurs prior to coding. Coding Clinic emphasized that clinical validation is a separate function from the coding process and the clinical skill embraced by CMS and cited in the AHIMA practice brief Clinical Validation: The Next Level of CDI.

Coding Clinic then went on to say that (emphasis mine):

“a facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.”

While I agree that facilities should standardize clinical definitions for clinical and coding validation purposes, note how Coding Clinic gave tremendous power to a payer to define any clinical term any way they want to. This may differ from that of a duly-licensed physician charged with direct face-to-face patient care responsibilities using the definitions of clinical terms he or she learned in medical school or read in their literature.

As such, while our facilities may implement clinical validation prior to ICD-10-CM code assignment, a payer that is not licensed to practice medicine and has no responsibilities for direct patient care, can require a provider or facility to use a completely different clinical definition that serves only one purpose in my mind, and that is to reduce or eliminate payment for care that was properly rendered, diagnosed, documented, and coded.

I’m sure that legal battles will ensue, given this caveat written by Coding Clinic.

Editor’s note: This post is an excerpt from an article originally published in JustCoding. Click here to read the full version.  Kennedy is the president of CDIMD-Physician Champions, a Nashville-based group of physicians, coders, and clinicians engaged nationwide as CDI physician advisors, ICD-10 medical informaticists, and DRG and HCC compliance advocates. His opinions do not necessarily reflect those of ACDIS or its Advisory Board. Contact him at

Guest Post (Part 3): Complying with definition changes

James S. Kennedy

James S. Kennedy

Note: This post is part three of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.

by James S. Kennedy, MD, CCS, CDIP

For those who have been reading along with my columns regarding sepsis documentation and coding challenges, allow me to suggest the following strategies to assure a balance of compliance :

  • Standardize the definition and documentation of severe sepsis first. Recovery Auditors (RAs) will be looking for records with sepsis codes that do not have R65.20 or R65.21 as a secondary diagnosis as to deny these codes and DRGs. So CDI specialists should work with medical staff to establish standardized definitions; this could incorporate any or all of the following three criteria:
    1. Change in SOFA score of 2 or more, which means that a new PaO2 of <60 on room air, or a Glasgow Coma Scale of 13 could, by themselves, generate the two points needed to qualify for an acute organ dysfunction. The physician would have to document what the organ dysfunction is, which may not necessarily be an organ failure, given that ICD-10-CM uses the word “dysfunction” rather than “failure” in justifying R65.20, severe sepsis. I suggest this be part of a standardized emergency department assessment template or admission order involving an infection, which means we must reprogram our electronic health record (Epic, Cerner, Meditech, McKesson) to systematize their capture.
    2. A lactate level of 2 mEq/L or more due to an infection. If the coder requires an organ dysfunction to go with R65.20, the physician would have to document tissue hypoperfusion for which no ICD-10-CM code is in the index to diseases. I suggest coding I99.8, other disorder of circulatory system.
    3. Any of the criteria described in SEP-1 (which can include a lactate level of 4 mEq/L or more to define septic shock). Note that SEP-1 documentation or order templates must be reviewed in light of what is needed for ICD-10-CM, given that these are signed by a provider, they may be used for coding purposes.

No matter what criteria you use, be sure to coordinate it with your quality and CDI/coding staff so if a physician documents “severe sepsis” or “septic shock,” the SEP-1 algorithm can be implemented. Also, be sure that physicians explicitly link organ dysfunctions to sepsis or preferably use the word “severe sepsis” so R65.20 is not inadvertently missed by the coders. As mentioned above, coders and CDI specialists should work closely with quality to ascertain if any of these organ dysfunctions in the setting of sepsis represent severe sepsis prior to claim submission. Here are my suggestions as to how to handle the current situation:

  1. Develop a facility-wide definition for sepsis without organ dysfunction. As you see above, many physicians in the United States do not believe that organ dysfunction is required to diagnose a patient with sepsis. Given that RAs are likely to use Sepsis-3 as a foundation for denying claims, you must have the statements of your internal medicine, critical care, and other physician committees as to what the definition of sepsis is for clinical and coding purposes so that when it is documented by a provider, this statement can be used to disprove the RA’s denials. These will be handy if you are appealing beyond the first level.
  2. Remind the RA that the ICD-10-CM guidelines is part of HIPAA and that coding is based on provider documentation, not the RA’s interpretation. I’m sure that all of our contracts with private-payers state that we will comply with federal law, such as HIPAA. Given that the 2017 ICD-10-CM Official Guidelines state that we are to assign ICD-10-CM codes based on provider documentation and that Coding Clinic, First Quarter 2014, pp. 16-17, states that “the official guidelines are part of the HIPAA code set standards.” We don’t want RAs to violate HIPAA or our contracts with payers, do we? This may require that a hospital attorney or compliance officer weigh in, given that RAs have been known to deny codes based on provider documentation.
  3. Be on the lookout for Coding Clinic advice clarifying this issue.  Coding Clinic for ICD-10-CM/PCS addressed some aspects of this in its fall 2016 publications for the third and fourth quarter. In addition to this advice, you may wish to submit your own cases to Coding Clinic advisors to see how they comment.

Editor’s note: This post is an excerpt from an article originally published in JustCoding. Click here to read the full version.

Guest Post (Part 2): Solving the documentation difficulties for sepsis-3

James S. Kennedy

James S. Kennedy

Note: This post is part two of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.

by James S. Kennedy, MD, CCS, CDIP

In developing a CDI strategy for dealing with new sepsis-3 criteria, remember three environments by which we must consider disease terminology and supporting criteria. One cannot talk about sepsis, severe sepsis, or septic shock documentation without considering the environment in which such documentation is to be interpreted.

Clinical language
Physicians use a language in direct-patient care that communicates (easily translates) well with other physicians. Every physician knows what “urosepsis,” “unresponsiveness,” and “neurotoxicity” is; however, ICD-10-CM does not recognize these terms for coding purposes, thus we ask physicians to use different words so coders can assign the correct coding conventions.

Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT) is a clinical language; so is sepsis-3. ICD-10-CM is not.

Not all physicians embrace sepsis-3, thus some may wish to label a patient has having sepsis even if they don’t have organ dysfunction, which makes clinical sense to them.

Coding language
In a landmark article published in the Journal of AHIMA in 2014, Sue Bowman, senior director of coding policy and compliance for AHIMA in Chicago, Illinois, makes it very clear that ICD-10-CM is not for clinical care but for administrative purposes.

“The standard vocabulary afforded by SNOMED CT supports meaningful information exchange to meet clinical requirements, Bowman says. “ICD-10-CM and ICD-10-PCS, with their classification structure and conventions and reporting rules, are useful for classifying healthcare data for administrative purposes, including reimbursement claims, health statistics, and other uses where data aggregation is advantageous,” she wrote.

Sepsis-3 amends clinical language only; however, for coding purposes we must still document using ICD-10-CM’s language, which still recognizes sepsis without organ dysfunction and sepsis with acute organ dysfunction (severe sepsis) and is based on the individual physician’s criteria.

Core measure language
Defining cohorts with core measures, such as SEP-1, is an abstraction based on clinical criteria and not necessarily based on what a physician writes.  For example, the definition of severe sepsis and septic shock is completely different in SEP-1 than Sepsis-3. We must remember, however, that in 2017, if a physician documents severe sepsis and R65.20 is coded, that record will be held accountable for the SEP-1 core measure even if it doesn’t meet the SEP-1 criteria. View this regulation here.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. The comments and opinions represent those of Kennedy and not necessarily ACDIS or its Advisory Board and advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions.Contact him at 615-479-7021 or at

Guest Post (Part 1): Documentation and coding challenges abound for sepsis-3

James S. Kennedy

James S. Kennedy

Note: This post is part one of four, excerpted from an article originally published in JustCoding. Click here to read the original. The comments and opinions represent those of Kennedy

by James S. Kennedy, MD, CCS, CDIP

There are a number of coding compliance challenges with sepsis-3 and with sepsis or severe sepsis in general. In this article, I’ll review my top four concerns.

First, sepsis-3 states that patients with an infection meeting the new sepsis criteria should be coded as R65.20, severe sepsis. This is impossible in the United States, given that ICD-10-CM code R65.20 can only be assigned if the physician documents “severe sepsis,” not sepsis alone, or if the physician documents that an acute organ dysfunction is associated with sepsis, though many coders fail to assign R65.20 when these links are made. Its apparent that the sepsis-3 authors are not familiar with Coding Clinic for ICD-10-CM/PCS, the Department of Justice, or our friendly neighborhood recovery auditors (RA).

Secondly, ICD-10-CM still has a multitude of codes for sepsis without organ dysfunction (e.g., A40-A41). The 2017 ICD-10-CM Official Guidelines for Coding and Reporting states that “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. It states:

The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.” (Emphasis added.)

Recent advice from Coding Clinic supports the concept that if an individual physician documents sepsis using his or her own criteria (that may differ from sepsis-3 or that of a RA), coders are obligated to code it. Therefore, if a physician documents sepsis, can we still defend the coding of an A40-A41 code if there is no documented organ dysfunction? I believe that the Guidelines and Coding Clinic say that we can, even if the RA doesn’t like it.

Thirdly, the ICD-10-CM table instructions for code R65.20, severe sepsis, tell us to use an “additional code to identify specific acute organ dysfunction.” If a physician documents severe sepsis based on the sepsis-3 criteria of a lactate over 2 milliequivalent per liter (mEq/L), or sepsis-3’s changes in the Glasgow Coma Scale, what is the organ dysfunction that should also be coded or queried for? Without an organ dysfunction documented and coded, a RA may claim that the severe sepsis code is invalid.

Finally, in my own personal review of the CMS 2015 MedPAR, approximately 45-55% of MS-DRGs 871 or 872 (septicemia or severe sepsis) do not have a code for severe sepsis, yet a number of patients have acute organ dysfunctions present on admission which I believe should have been linked to the patient’s sepsis to render the severe sepsis code.

RAs look at sepsis DRGs without R65.20, severe sepsis, or R65.21, septic shock, as opportunities to take money away from facilities who coded sepsis (e.g., A40-A41) as present on admission and sequenced it as a principal diagnosis without an additional R65.20 or R65.21 code. To take these records out of the RA data mining pool, CDI professionals must make every effort to query providers if the clinically valid indicators of organ dysfunction due to sepsis are present but the record does not have the documentation interpreting these indicators as to report R65.20 and R65.21 and their associated organ dysfunctions. This effort, however, must be coordinated with the SEP-1 or quality manager, given that any coding of R65.20 or R65.21 subjects the record to the SEP-1.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. The comments and opinions represent those of Kennedy and not necessarily ACDIS or its Advisory Board and advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions.Contact him at 615-479-7021 or at

Guest Post: Look at the nuanced sepsis definitations before querying

Dr. Robert S. Gold

Dr. Robert S. Gold

By Robert S. Gold, MD

The incidence sepsis cases within the United States has quadrupled while the length of stay of these cases and the mortality has decreased. And Recovery Auditors have denied numerous claims because, at least in part, CDI staff queried to get sepsis DRGs when the patient didn’t have sepsis. While these professionals may have followed the letter of the law in terms of query compliance, they often do not follow the clinical letter of the law.

There’s sepsis and there’s alternative terms that are not sepsis.

Putting a patient on a “sepsis protocol” is not a diagnosis of sepsis. A sepsis protocol says the patient may have an infection and it may have advanced far enough to be serious and have systemic manifestations with increased risk of death, or it may turn out, after workup, that it wasn’t sepsis at all, or it may not be an infection at all.

A patient who has criteria of systemic inflammatory response syndrome (SIRS) has abnormalities in vital signs or abnormalities of lab tests. That alone is not sepsis under any circumstances—until it’s proven to be sepsis. Most patients do not exhibit the clinical indicators to even meet the criteria and, in many that did meet the criteria, the abnormalities had nothing to do with the infection.

Acute diverticulitis is acute diverticulitis. Acute otitis media is acute otitis media. Most bacterial infections have two of the four criteria of SIRS and most of these patients are not sick. Most patients seen in an emergency room with an infection and two of the four criteria that look like SIRS actually go home.

Using the term “sepsis syndrome” is another way of trying to get around truth. Once upon a time, “sepsis syndrome” actually meant sepsis; however it has evolved to be equivalent to SIRS and has no validity as a codable term at all until, and if, it is determined that the patient has actually has sepsis.  In fact, Coding Clinic even came to that conclusion in Second Quarter 2012 p. 21, and people who are assigning sepsis codes based on documentation of “sepsis syndrome” are taking quite a risk.

Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs, including needs for ICD-10. Contact him at 770-216-9691 or This article was originally published in the DCBA enewsletter CDI Talk.

Q&A: Creating a compliant query for SIRS and/or sepsis

Submit your inpatient coding and CDI questions reply to this post .

Submit your CDI questions by replying to this post .

Q: I have been asked to build a query for a diagnosis of SIRS and/or sepsis for the following scenario: The patient was admitted for an infection urinary tract infection (UTI), Pyelonephritis (PNA) and meets two SIRS criteria. The patient may be treated with oral or intravenous antibiotics, and may be on a general medical floor (not intensive care). The physician did not document SIRS or sepsis. I am having a hard time with this query because I am not sure if this would be considered adding new information to the chart, leading the physician, by introducing a new diagnosis. Do you have any suggestions?

A: Although many CDI and coding professionals feel offering a new diagnosis as a choice in a multiple choice query or clarification is considered introducing new information, the 2013 Guidelines for Achieving a Compliant Query Practice states,

“[P]roviding a new diagnosis as an option in a multiple choice list, as supported and substantiated by referenced clinical indicators from the health record, is not introducing new information.”

Thus, if you have a patient that demonstrates clinical indicators to support the diagnosis of sepsis, you may submit a query to clarify if this diagnosis is appropriate. In the body of the query, you would also include those clinical indicators and evidence of treatment that supports your rational for querying the physician.

That said, use the SIRS criteria to support sepsis, with caution. The criteria cannot be explained by another existing condition—for example, tachycardia when the patient has atrial fibrillation.  Review the Surviving Sepsis Campaign’s nationally supported clinical criteria and treatment bundles that can be used to support the diagnosis of sepsis.

Here’s an example query that you might use:

Dear Doctor;

Patient 2345 was admitted with a UTI. The ED record indicates patient was febrile with a temperature of 102.7, heart rate of 98, Laboratory results showed a white blood cell count of 13,500 with 12% bands, hyperlactatemia, and altered mental status. Blood cultures pending. Antibiotics ordered with fluid bolus.

Based on these clinical indicators, can the patient’s status be further clarified as:

  1. UTI with sepsis
  2. UTI only
  3. Other _____________________
  4. Unable to determine

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at For information regarding CDI Boot Camps visit

Q&A: Sepsis, septic shock, still cause for query confusion

Ask your question!

Ask your question!

Q: If the physician writes septic shock instead of sepsis do I need to query for sepsis or is this an integral part and sepsis would be the principal diagnosis and the septic shock would be secondary, making it a MCC?

A: You are not alone if you find the coding of sepsis to be challenging. In the case you describe above the documentation of septic shock would support both codes for the septicemia and the severe sepsis. (Septic shock cannot occur without sepsis and severe sepsis being present). You would need to add codes for the underlying condition (local infection) as well as codes for the organ dysfunction resulting from the sepsis that support the presence of severe sepsis. It is also a good practice to assign the code for causal organism if known.

The septic shock would provide the MCC as the secondary diagnosis.

The Official Guidelines of Coding and Reporting specifically outline the coding practices for sepsis, severe sepsis, and septic shock very clearly in the chapter Specific Coding Guidelines- Chapter 1: Certain Infectious and Parasitic Diseases. I always suggest that new CDIs take time to read the guidelines to assist with the special considerations related to this diagnosis.

Again, you are not the only one who has struggled with this difficult topic. For some additional reading please take a look at these previous articles and recommendations from the ACDIS website: