Coding, Classification & Reimbursement

Subject: Severe Sepsis and Organ Failure

1.  Severe Sepsis and Organ Failure

Posted 05-18-2017 14:56
When coding a sepsis case and you have a physician mentioning in his documentation acute renal failure, acute respiratory failure, etc..  do you rely on the physician to make the connection between the sepsis and the organ failures before you code the severe sepsis or do you code the severe sepsis if the patient has the organ failures in addition to the diagnosis of sepsis?  Just wanted to be clear as our physicians are not clear in linking the organ failures mentioned in their documentation back to the diagnosis of sepsis, just wanted to make sure if we should be querying or not?  Thanks so very much for your opinions on this!

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Pamela Schinke, RHIA, CCS
Coding Manager
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2.  RE: Severe Sepsis and Organ Failure

Posted 05-18-2017 15:05
We query for the link if the provider does not make the link in the documentation, for example, ATN in the setting of sepsis, or ATN 2/2 severe infection/sepsis.  Coders cannot assume the link.

We send a lot of queries.

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Hope this helps
Jennifer Ritter, BS, RHIT, CCS
Coding Manager/Educator
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3.  RE: Severe Sepsis and Organ Failure

Posted 05-18-2017 15:10
Hi Pamela 

Below I have pasted a portion of the 2017 guidelines that addresses this issue hope it helps.

If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2, 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. 



Thank you,
Amanda LeBron





4.  RE: Severe Sepsis and Organ Failure

Posted 05-19-2017 09:40
Dear Pamela,

As a coder, one cannot assume that there is a correlation between ANY TWO DIAGNOSES unless the physician has actually documented the relationship. If you feel that there is a correlation or that you are unsure as to the relationship then you would query the physician. We as coders are detectives not diagnosticians.

Jodi Miller, RHIT, CCS

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Jodi Miller, RHIT, CCS
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5.  RE: Severe Sepsis and Organ Failure

Posted 05-20-2017 10:04

Greetings!
Per 2017 ICD-10-CM Official Guidelines for Coding and Reporting, there are times when the classification presumes a causal relationship between certain diagnoses. For example, hypertension and kidney involvement, and now hypertension and heart involvement. For Severe Sepsis the guidelines specify for us:

Section I.C.d.1.a.iv
"Acute organ dysfunction that is not clearly associated with Sepsis - if a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than sepsis, do not assign a code from subcategory R65.2, 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".

With warm regards,



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Kathy Pelanek, RHIT
Coding Educator/Team Lead Coder
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6.  RE: Severe Sepsis and Organ Failure

Posted 05-20-2017 07:27
Hello!

Per the Official Coding Guidelines,

"The word 'with' should be interpreted to mean 'associated with' or 'due to' when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular ListThe classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List.  These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related."


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Lawrence Barr
President
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7.  RE: Severe Sepsis and Organ Failure

Posted 05-20-2017 09:03
Edited by Laurie Zawiskie 05-20-2017 09:05
Doesn't this seem like conflicting advice? The guideline Amanda mentioned says not to assume a link, but the "with" guideline Lawrence mentioned would indicate we would assume a link.

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Laurie Zawiskie
Coder III
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8.  RE: Severe Sepsis and Organ Failure

Posted 05-20-2017 10:24
Edited by Kathy Pelanek 05-20-2017 10:31
I think confusion is coming from the "link" in the alphabetical index listing Sepsis, with, organ dysfunction R65.20.

But we never use the index to assign a code, we always go to the tabular to assign the correct code, and in the tabular it specifies R65.2 Severe Sepsis - Infection with associated acute organ dysfunction.

So even though it looks like you're good to go from the index, once you get to the tabular it does sync up with the coding guidelines, that an acute organ dysfunction must be associated with the sepsis (by the physician) in order to assign the severe sepsis code.

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Kathy Pelanek
Coding Educator/Team Lead Coder

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9.  RE: Severe Sepsis and Organ Failure

Posted 05-21-2017 09:05
Associated with also presumes a causal relationship--"The classification presumes a causal relationship between the two conditions linked by these terms ("with", associated with", or "due to") in the Alphabetical Index or Tabular List."  "These conditions should be coded as related even in the absence of provider documentations explicitly linking them, unless the documentation clearly states the conditions are unrelated."   So unless there is documentation specifically stating that the conditions are unrelated the Classification presumes the linkage.

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Karen Neal
Coding Quality Auditor
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10.  RE: Severe Sepsis and Organ Failure

Posted 05-20-2017 10:08
The Alphabetical Index makes the linkage between the two conditions with the connecting term "with". Section I.A.15 Guidelines states: "The classification presumes a causal relationship between the two conditions linked by these terms ("with", associated with", or "due to") in the Alphabetical Index or Tabular List. These conditions should be coded as related even in the absence of provider documentations explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related."  In the Alphabetical Index under Sepsis with organ dysfunction(acute) (multiple) R65.20. So if a patient had sepsis with kidney failure, you would assign A41.9, R65.20, and N17.9.

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Karen Neal
Coding Quality Auditor
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11.  RE: Severe Sepsis and Organ Failure

Posted 05-21-2017 07:55
Hello!

My edition of the 2017 ICD-10-CM as published by CMS has the following entries:

Index - Sepsis (generalized) (unspecified organism) A41.9
            - with
            - - organ dysfunction (acute) (multiple) R65.20
               - - - with septic shock R65.21

Tabular - R65.2 Severe sepsis
                           Infection with associated acute organ dysfunction
                           Sepsis with acute organ dysfunction
                           Sepsis with multiple organ dysfunction
                           Systemic inflammatory response syndrome due to infectious process with acute organ dysfunction.

I supplied the underlining.

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Lawrence Barr
President
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12.  RE: Severe Sepsis and Organ Failure

Posted 05-22-2017 15:58
This issue was submitted to the Coding Clinic Editorial Advisory Board.

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Suzanne Drake
Coding Quality and RAC Coordinator
Bon Secours Richmond Health System
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13.  RE: Severe Sepsis and Organ Failure

Posted 05-25-2017 21:35
Hi, my name is Gina and I am currently enrolled in my final semester at Alfred State.  I found this discussion post to be educational and I'm curious to know what the correct code would be for this situation.  I attended a local AHIMA meeting and there too, a coding question regarding Sepsis was front and center.  I have not had experience coding Sepsis diagnosis but it does seem it can be very challenging.

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Gina Besner
Student, Alfred State College
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