Angela Sniffen, MPA, RN, CCDS, CCS Phelps Hospital April 12, 2018 Sepsis Angela Sniffen, MPA, RN, CCDS, CCS Phelps Hospital April 12, 2018

Clarification of severe sepsis guideline Coding Clinic, Fourth Quarter 2017, pages: 99-100 Question: Please advise which guidelines apply when coding sepsis with organ dysfunction. Should we follow the coding convention "with" and assume a causal relationship? Alternatively, are the chapter specific guidelines for sepsis more appropriate? Does the physician need to document the relationship between sepsis and organ dysfunction? The guidelines appears to conflict with the coding convention in the classification. Per the instructions in the guidelines, the conventions in classification take precedence.

Clarification of severe sepsis guideline Answer: Provider documentation must specifically link an acute organ dysfunction with sepsis in order to assign the severe sepsis code. The "with" guidelines state that when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for "acute organ dysfunction that is not clearly associated with the sepsis"), then provider documentation must link the conditions in order to code them as related. It is also appropriate to assign a code for severe sepsis when the provider documents "severe sepsis," or when the Index to Diseases directs to the code for "severe sepsis." Effective October 1, 2017, the "with" guideline (Section I.A.15) has been revised to clarify "When a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related." The sepsis guideline for "acute organ dysfunction that is not clearly associated with sepsis" is an example of this exception, and the "with" guideline would not apply since another guideline exists that specifically requires a documented linkage. Please refer to page 79 of this issue of Coding Clinic for the specific revision

Coding Clinic, Fourth Quarter ICD-10 2017 pages 79-80 A. Conventions for ICD-10-CM 10/01/2017 15. “With” The word "with" or "in" 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 List. The 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 or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for "acute organ dysfunction that is not clearly associated with the sepsis"). For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related. . . .

Case Study Summary: 40 year old female with a history of several days of nausea, vomiting, fever and chills as well as right flank pain. Found to have an obstructing right ureteral calculus with hydronephrosis. WBC 15, UA positive, temperature 104-102, P 75-124, RR 20 to 32. Postoperative Diagnoses: Obstructing proximal ureteral stone surrounded by 15 mm of infectious matrix consistent with calculous pyelonephritis. PROCEDURES: Cystoscopy; retrograde pyelogram; ureteroscopic disimpaction of proximal ureteral stone with mechanical aspiration of infected material from renal pelvis; laser lithotripsy to fragment thick material for aspiration through endoscope; placement of intrarenal stent and Foley catheter.

Query Impact Opportunity: Query for Sepsis Impact: DRG 670 Transurethral procedures without cc, weight .9836 DRG 854 Infectious and Parasitic Diseases w OR procedure w/cc, Weight 2.3912 Financial Impact: $31,384

Thank You kseekircher@nwhc.net January 18, 2018