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November 7, 2011

Coding for Sepsis and SIRS
For The Record
Vol. 23 No. 20 P. 28

Coding for sepsis and systemic inflammatory response syndrome (SIRS) is a challenge. There has been much clinical discussion about the conditions and their definitions, but a discrepancy remains regarding how physicians apply the definitions to their patients. Coders also have several guidelines they must follow as stated in the ICD-9-CM Official Guidelines for Coding and Reporting.

Sepsis, severe sepsis, and SIRS were initially defined by a consensus panel convened by the American College of Chest Physicians and the Society of Critical Care Medicine in 1991 and readdressed in 2001 by these groups along with the American Thoracic Society, the European Society of Intensive Care Medicine, and the Surgical Infection Society. The consensus of definitions from 2001 includes the following:

• SIRS can be triggered by a variety of infectious and noninfectious conditions. Signs of systemic inflammation may occur in the absence of infection in patients with burns, pancreatitis, and other diseases. Physician participants are hopeful to use only biochemical or immunological data in the future. Currently, however, the physician must use clinical manifestations to diagnosis SIRS. The original definition of SIRS required that the patient have one of the following manifestations:

— a fever higher than 100.4˚F or hypothermia (temperature less than 96.8˚F);

— leukocytosis (white blood count of greater than 12,000 cells/mm3), leukopenia (white blood count fewer than 4,000 cells/mm3), or left shift (greater than 10% bands);

— tachycardia (more than 90 heartbeats per minute); or

— tachypnea (respiratory rate of more than 20 breaths per minute ) or arterial blood gas less than 32 mm Hg.

However, this diagnostic criterion was deemed to be overly sensitive and nonspecific.

• Sepsis is a clinical syndrome defined by the presence of both infection and a systemic inflammatory response. Certain biological markers were identified (eg, interleukin 6, procalcitonin, C-reactive protein) as pointing to the inflammatory response in sepsis patients. However, due to a lack of epidemiological data, there is no recommendation for inclusion of those criteria.

• Infection is a pathological process caused by the invasion of normally sterile tissue or fluid or body cavity by pathogenic or potentially pathogenic microorganisms. This is not a perfect definition because not all infections are caused by bacteria invading sterile tissue (eg, Clostridium difficile). Also, an infection may be diagnosed based on clinical signs and symptoms and not confirmed by microbiology.

• Severe sepsis is sepsis complicated by organ dysfunction.

• Septic shock is a state of acute circulatory failure characterized by persistent arterial hypotension unexplained by other causes.

Hypotension can be defined as having one of the following despite adequate volume resuscitation in the absence of another cause of hypotension:

— a systolic arterial pressure below 90 mm Hg;

— a mean arterial pressure lower than 60; or

— a reduction in systolic blood pressure of more than 40 mm Hg from baseline.

ICD-9-CM Official Guidelines for Coding and Reporting has defined the conditions, including septicemia, as follows:

• Septicemia is a systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi, or other organisms.

• SIRS is a systemic response to infection, trauma or burns, or other insult (such as cancer), with symptoms including fever, tachycardia, tachypnea, and leukocytosis.

• Sepsis is SIRS due to infection.

• Severe sepsis is sepsis with associated acute organ dysfunction.

• Septic shock refers to circulatory failure associated with severe sepsis.

Physicians frequently use the term bacteremia, which is generally defined as the presence of bacteria in the blood and denotes only an abnormal laboratory finding. If sepsis symptoms are present, the physician should be queried for a more precise diagnosis.

ICD-9-CM Coding
SIRS is frequently associated with infectious processes. However, there are many noninfectious conditions in which SIRS can develop. According to coding guidelines, the code for SIRS (995.90 to 995.94) should never be sequenced as a principal diagnosis. If SIRS is caused by an infection, coding rules require septicemia (038.x) to be listed first. If SIRS is caused by a noninfectious process, then that condition would be listed first.

Sepsis requires two codes to classify the condition. The first is the systemic infection code and is usually found in category 038. However, it may be found elsewhere depending on the organism. For example, sepsis due to candidiasis is classified to codes 112.5 and 995.91.

Infection is not restricted to only bacterial infection as it is relates to SIRS. Coding guidelines state, “Septicemia generally refers to a systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi, or other organisms.” The guidelines also state that “sepsis generally refers to SIRS due to infection.” For example, if the physician documented sepsis or SIRS due to a virus, code 038.8 should be sequenced first followed by code 995.91 and a code for the specific viral infection (such as 487.1 for influenza). If only SIRS due to viral syndrome is documented, assign codes 038.8, 995.91, and 079.99.

Septicemia is coded like sepsis except that it does not require code 995.91 as a secondary diagnosis. Severe sepsis also requires two codes for complete classification: the systemic infection code and code 995.92. According to page 18 of the ICD-9-CM Official Guidelines for Coding and Reporting, “If a patient has sepsis and an acute organ dysfunction, but the medial record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign code 995.92, Severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.” So there must be some sort of a link between the organ dysfunction and the sepsis before the condition can be classified as severe sepsis. Without a link, the organ dysfunction (such as acute renal failure or acute respiratory failure) would still be coded, but it would not be coded as severe sepsis without the documented association between the two.

Documentation of septic shock is assumed to be severe sepsis, and coding guidelines indicate that the underlying infection should be listed first (typically a code from category 038) followed by severe sepsis (995.92) and then septic shock (785.52).

If sepsis is present on admission, it will be sequenced as the principal diagnosis over the localized infection (eg, pneumonia, cellulitis, urinary tract infection) causing the sepsis. If the documentation is unclear as to whether the sepsis was present on admission, the physician should be queried for clarification.

Additionally, the sepsis diagnosis should be a consistent “theme” throughout the body of the chart if it is the principal diagnosis. When unclear, query the physician about whether sepsis is an appropriate diagnosis or if sepsis was an appropriate diagnosis that is now currently resolved.

Manifestations of Sepsis and Severe Sepsis
Common manifestations of sepsis include the following:

• altered mental status, including confusion, irritability, and lethargy;

• bandemia;

• elevated C-reactive protein and/or procalcitonin;

• fever, chills, or myalgias (temperature of 100.4˚F or higher)

• hyperglycemia in diabetes;

• hyperlactatemia;

• hypoventilation;

• hypoxemia;

• leukocytosis and/or left shift;

• positive blood culture for bacteria (may or may not have positive blood cultures);

• proteinuria;

• skin rash;

• tachycardia; and

• tachypnea.

The physiologic changes should represent an acute alteration from baseline in the absence of other known causes for abnormalities, such as chemotherapy-induced neutropenia and leukopenia.

Blood cultures are a helpful part of a clinical workup for sepsis. Through the identification of organisms, optimal antimicrobial selection can be achieved. However, many factors can limit the ability to obtain a positive blood culture, including long-term use of antibiotics, recent antibiotic administration, transient bacteremia, or sample quality. Only 30% to 50% of patients with sepsis have positive blood culture results. Query the clinician for sepsis when the total clinical picture and treatment is indicative of sepsis despite lack of positive blood cultures.

Manifestations seen in severe sepsis or septic shock include the following:

• acute liver, renal, or respiratory failure;

• adult respiratory distress syndrome;

• cold, clammy, grayish-blue (cyanotic) skin;

• disseminated intravascular coagulation;

• encephalopathy;

• hypoglycemia;

• hypophosphatemia;

• hypotension;

• hypothermia;

• increased cardiac output with a low systemic vascular resistance;

• increased oxygen consumption;

• leukopenia/leukemoid reaction;

• metabolic acidosis due to impaired organ function (pH of less than 7.30 and a plasma lactate higher than 1.5 times);

• the upper limit of normal for the lab;

• oliguria/decreased urine output (less than 0.5 mL/kg/hour for one hour in the face of adequate intravascular volume or after adequate fluid challenge);

• prothrombin-international normalized ratio greater than 1.2 that cannot be explained;

• shock;

• stupor or coma; and

• thrombocytopenia (fewer than 100,000 platelets/mm3).

Treatment of sepsis, severe sepsis, and septic shock is dependent on the organism(s) involved and clinical progression but may include the following:

• broad-spectrum IV antibiotics (eg, cefepime, ceftazidime, ciprofloxacin, Levaquin, moxifloxacin, timentin, tobramycin, vancomycin, and Zosyn);

• corticosteroids (stress or replacement doses);

• dialysis;

• IV hydration/fluid challenges;

• inotropes/vasopressors;

• mechanical ventilation;

• monitoring of lab work, including complete blood count, chemistry, C-reactive protein, procalcitonin, coagulants, and arterial blood gas;

• Swan-Ganz; and

• Xigris.

Central Line-Associated Bloodstream Infection
Based on current coding advice and coding directives, code 999.32, Bloodstream infection due to central venous catheter, followed by code 790.7, Bacteremia, should be assigned for bacteremia due to a peripherally inserted central catheter (PICC) line.

Bacteremia due to a PICC line is classified to codes 999.31 and 790.7, according to  AHA Coding Clinic for ICD-9-CM, 2011, second quarter, pages 7-8. This advice was published before the creation of codes 999.32 to 999.34, which became effective on October 1. Therefore, with the creation of the new codes, it would stand to reason that code 999.32, Bloodstream infection due to central venous catheter, followed by code 790.7, Bacteremia, should be assigned for bacteremia due to a PICC line.

Coding and sequencing for sepsis and SIRS are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.


Coding for Sepsis in ICD-10-CM
Sepsis is classified as sepsis or septicemia due to an organism, and only one code is required to classify this disease process. Severe sepsis is reported as an additional condition and includes sepsis with or without septic shock. Physician documentation of associated organ dysfunction and severe sepsis with or without septic shock is required for appropriate classification of the disease.