1. CDI and Coding Considerations
SEPSIS
CDI and Coding Considerations

2. Sepsis Redefinition (Sepsis-3) February 23, 2016
Announced at the SCCM meeting in Orlando on February 22, 2016
Published in JAMA on February 23, 2016

3. The SIRS Criteria is valid to the extent that a systemic inflammatory response can be triggered by a variety of infectious and non- infectious conditions.
*Signs and Systemic Inflammatory do occur in the absence of infection. For Example Burns, Pancreatitis and other disease states.

4. Sepsis Redefinition February 23, 2016
Sepsis is now defined as a ‘life-threatening organ dysfunction due to a dysregulated host response to infection’
In this new definition the concept of the non- homeostatic host response to infection is strongly stressed while the SIRS criteria have been removed
The inflammatory response accompanying infection (pyrexia, neutrophilia, etc) often represent an appropriate host response to any infection, and this may not necessarily be life-threatening.

5. Sepsis
Specify if patient has “Probable, possible or suspected” sepsis on admission. The physician’s opinion of clinical sepsis should be documented. Positive blood cultures are not necessary per Coding Clinic Guidelines
Do not use “Urosepsis” if the patient’s condition is sepsis (definitive or suspected) from a urinary tract source. Urosepsis is an ambiguous term that classifies and codes to UTI.
Bacteremia is not synonymous with a sepsis diagnosis
Positive blood cultures are not requires (Source: Coding Clinic, Third Quarter, 1988, page 1)

6. Sepsis Redefinition February 22, 2016
Septic shock is now defined as a ‘subset of sepsis where underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality’.
Clinical criteria identifying such condition include the need for vasopressors to obtain a MAP≥ 65mmHg AND an increase in lactate concentration > 2 mmol/L, despite adequate fluid resuscitation.*
This new definition is mainly focused on the importance to both distinguish septic shock from other forms of circulatory shock and underline the detrimental clinical impact of sepsis-induced cellular metabolism abnormalities.*
* Doesn’t mean one can’t have other forms of shock (e.g. cardiogenic, hypovolemic, or obstructive shock); if these are present, then they should be documented.

7. Sepsis Redefinition February 23, 2016
The key element of sepsis-induced organ dysfunction is defined by ‘an acute change in total SOFA score ≥ 2 points consequent to infection, reflecting an overall mortality rate of approximately 10%
The baseline Sepsis-related Organ Failure Assessment (SOFA) score may be taken as zero unless the patient is known to have previous comorbidity (e.g. head injury, chronic kidney disease, etc.)
In light of this, the current definition of 'severe sepsis' becomes obsolete, as does the term “SIRS”

8. Coding Implications Severe Sepsis
SOFA score alone does not give me the words serving as “acute organ dysfunctions”

9. Sepsis
Distinguish the terms for the presence of an organism in the blood as: Bacteremia (patient may not be symptomatic) and Sepsis (patient typically is symptomatic).
Sepsis = SIRS due to infection. That doesn’t mean if the patient meets the SIRS criteria they necessarily have Sepsis.
Lactate Levels > 2.0 mmol/L (>4.0 is equivalent to septic shock)
Positive blood cultures are not requires (Source: Coding Clinic, Third Quarter, 1988, page 1)

10. Coding Implications Severe Sepsis
SOFA score alone does not give me the words serving as “acute organ dysfunctions”

11. Coding Implications Severe Sepsis
SOFA score alone does not give me the words serving as “acute organ dysfunctions”

12. Endorsing Entities . . . . . .

13. Coding Implications ICD-10-CM
While Sepsis-3 requires acute organ dysfunction to define sepsis, a provider must document “severe sepsis” or link the organ dysfunction to sepsis to obtain a code for severe sepsis

14. MS-DRG 870-872 Validity Before and After Sepsis-3

15. Coding Clinic, 1st Q, 2012, p.19 Sepsis Validity
Question: The patient was transferred to the long term care hospital (LTCH) following a lengthy hospitalization for sepsis and acute respiratory failure
She was transferred to the LTCH for further intravenous antibiotic treatment and management of her multiple medical problems including resolving coagulase- negative staphylococcus sepsis, and respiratory failure
Since the sepsis is resolving would it be appropriate to code sepsis as the principal diagnosis?
Answer: The Editorial Advisory Board (EAB) for Coding Clinic has become aware of a pattern of documentation problems concerning patients transferred to the LTCH with a diagnosis of sepsis
Physician advisers reviewing these cases did not agree that these patients were truly septic since they had no clinical indicators
If the documentation is unclear as to whether the patient is still septic, query the provider for clarification
Facilities should work with the medical staff to improve physician documentation and address any documentation issues

16. Coding Implications Before and After Sepsis-3
Before Sepsis-3
A systemic infection code (e.g. A41.9) could be coded without a R65.2x code and still be considered valid if reasonable criteria are met
After Sepsis-3
It is Dr. Kennedy’s opinion that if
the systemic infection code (e.g. A41.9) is coded without a R65.2x code OR
an organ dysfunction code is not documented to be associated with sepsis AND/OR it is not coded at all
that a code for sepsis can be legitimately challenged as a valid diagnosis since no organ dysfunction is present
That if the systemic infection code or the R65.2x code is not POA that the systemic infection code (e.g. A41.9) cannot be the principal diagnosis

17. MS-DRG 870-872 Validity Before and After Sepsis-3
Principal Diagnoses Qualifying for MS-DRG , Sepsis
A021
Salmonella sepsis
A207
Septicemic plague
A227
Anthrax sepsis
A267
Erysipelothrix sepsis
A327
Listerial sepsis
A391
Waterhouse-Friderichsen syndrome
A392
Acute meningococcemia
A393
Chronic meningococcemia
A394
Meningococcemia, unspecified
A3989
Other meningococcal infections
A399
Meningococcal infection, unspecified
A400
Sepsis due to streptococcus, group A
A401
Sepsis due to streptococcus, group B
A403
Sepsis due to Streptococcus pneumoniae
A408
Other streptococcal sepsis
A409
Streptococcal sepsis, unspecified
A4101
Sepsis due to Methicillin susceptible Staphylococcus aureus
A4102
Sepsis due to Methicillin resistant Staphylococcus aureus
A411
Sepsis due to other specified staphylococcus
A412
Sepsis due to unspecified staphylococcus
A413
Sepsis due to Hemophilus influenzae
A414
Sepsis due to anaerobes
A4150
Gram-negative sepsis, unspecified
A4151
Sepsis due to Escherichia coli [E. coli]
A4152
Sepsis due to Pseudomonas
A4153
Sepsis due to Serratia
A4159
Other Gram-negative sepsis
A4181
Sepsis due to Enterococcus
A4189
Other specified sepsis
A419
Sepsis, unspecified organism
A427
Actinomycotic sepsis
A5486
Gonococcal sepsis
B007
Disseminated herpesviral disease
B377
Candidal sepsis
R571*
Hypovolemic shock
R578*
Other shock
R6510**
Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction
R6511**
Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction
R6520**
Severe sepsis without septic shock
R6521**
Severe sepsis with septic shock
R7881*
Bacteremia
* As a Chapter 18 “symptom code”, it cannot be the PDx if the underlying condition is known
** Can never be the PDx according to the ICD-10-CM Guidelines

18. Sepsis Criteria for SIRS must meet two or more of the following:
Fever > 38.3°C or hypothermia < 35° C, Hypotension
Leukocytosis-WBC > 12,000 or leukopenia, WBC < 4,000 or >10% bands
Tachycardia->90 beats/minute
Tachypnea-RR > 20 breaths/minute or PaCO2 < 32mmHg
***Because tachypnea and tachycardia are so common in hospitalized patients for many reasons, they should not ordinarily be used as the only two criteria for diagnosing sepsis.

19. Sepsis Altered Mental Status
Mottling of the skin or prolonged capillary refill
Non-diabetic hyperglycemia (blood Sugar >120)
Other evidence of acute organ failure (severe sepsis)
***The diagnosis of sepsis depends entirely on the physician’s clinical interpretation of these criteria and their significance.

20. Sepsis
If these findings can, in the physician’s judgment, be “easily explained by another coexisting condition (other than the underlying infection), it should be excluded by the physician when deciding whether the patient has sepsis.

21. Sepsis ICD 10 tips
Ask?
Is it Severe, with shock, with a localized infection, POA, due to post procedural infection, Bacteremia vs. Sepsis (presence of bacteria in the blood
Sirs is not synonymous with sepsis. If sirs occurs in presence of sepsis make sure to include both terms.

22. Sepsis
Sepsis is coded with only code (A41.9 is for unspecified sepsis). Severe sepsis requires a code for sepsis (A41.9), followed by the code for sever sepsis (R65.20), with an additional code to identify the specific acute organ dysfunction.
In ICD-10, Sepsis must be specifically diagnosed since there is no code for “SIRS due to infection” as in ICD-9. ICD-10 has no code for urosepsis and provider must be queried.

23. Query Query if clinical indicators are present BPA fires
Underlying infection
Febrile, WBC
SIRS criteria Met
Other findings supporting the potential dx
Conflicting data
Procedures r/t to
End Organ
BPA fires

24. Septic Shock Presentation
Tissue hypoperfusion persistent after fluid administration evidenced by any of the following conditions:
Systolic blood pressure below 90
Mean arterial pressure below 65
A decrease in systolic blood pressure by more than 40 points
Lactate level over 4 mmol/L
Blood cultures
Antibiotics

25. Sepsis Crystalloid fluids administered .9% NS or Lactated Ringers.
Watch for documentation of Hypotension:
Systolic BP lower than 90
Mean arterial pressure lower than 65
A decrease in systolic blood pressure by more than 40 points
If hypotension persists after fluid is given, look for the administration of IV Vasopressor
Heart and Lung Assessment findings

26. Conflicting Documentation
The documentation of the attending provider supersedes that of all other providers; however, many organizations allow individual providers within the same practice to “share” the role of the attending provider.
The role of the attending providers and the relationship with “consulting” providers has drastically changed in recent years as the attending more often coordinates care and defers to the consulting provider for specific guidance on specific conditions.
Information obtained from the following sources: HcPro, Acdis

27. AHIMA/ACDIS 2013 Query Recommendation
Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
Provides a diagnosis without underlying clinical validation
Is unclear for present on admission indicator assignment
Information obtained from the following sources: HcPro, Acdis, AHIMA

28. Sepsis
Are any of the following organ dysfunction criteria present at a site remote from the site of the infection that are not considered to be chronic conditions?
Acutely altered mental status
SBP less than 90 or MAP less than 65 mmHg
SpO2 less than 90% on room air or on supplemental O2
Creatinine greater than 2 mg/dL (176.8 mmol/L) or Urine Output less than 0.5 mL/Kg/hour for greater than 2 hours
Bilirubin greater than 2 mg/dL (34.2 mmol/L)
Platelet count less than 100,000 μL
Lactate greater than 4 mmol/L

29. Developing Queries for Sepsis
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.
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
- See more at:

30. Would this be considered adding new information to the chart, leading the physician, by introducing a new diagnosis?
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
- See more at:

31. “Providing 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.”
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
- See more at:

32. Reverse Queries
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.

33. Use the SIRS criteria to support sepsis, with caution
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.
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
- See more at:

34. Query Example
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:
UTI with sepsis
UTI only
Other _____________________
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
- See more at:

35. Scenarios
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.
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.
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
- See more at:

36. Scenario
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.

37. Scenarios
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.

38. Scenarios
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.

39. Scenarios
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.

40. Scenarios
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 coded 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.

41. QUESTIONS? Thanks for your time!