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All sepsis now is the condition formerly known as severe sepsis.

EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Aug. 13 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting.

I’m the co-chair of the American College of Physician Advisors CDI Education Subcommittee. In writing the information for Physician Advisors on sepsis, I read a lot of materials regarding the SEP-1 bundle, also referred to as the Sepsis Core Measures. I found some interesting points that I want to share with you.

Unlike many of the quality metrics which come from the ICD-10-CM codes we capture from the clinician’s documentation, SEP-1 is abstracted. That means there is a magic Sepsis abstraction quality fairy who reads through charts and determines whether the core measure was applicable or not, and whether we met the criteria or not. It is dependent on both documentation and data.

There are very strict rules and guidance and commentary on the rules by CMS. The algorithmic process is complex.

Severe sepsis and septic shock trigger the core measures. It is my opinion that under the current definition of sepsis, that is, life-threatening organ dysfunction due to the dysregulated host response to infection, all patients with sepsis should trigger SEP-1. All sepsis now is the condition formerly known as severe sepsis.

There are organizations who philosophically choose to retain the definition of sepsis as being presumed or confirmed infection plus SIRS (which is 2/4 of temperature derangement, tachycardia, tachypnea, and abnormal white count). These charts will provoke review by the quality team, but if there is no organ dysfunction, they will not meet SEP-1 criteria.

On the other hand, if providers no longer use the phrase, “severe sepsis,” because it has been eliminated from the medical lexicon, they are not protected from being included because the R65.20 code isn’t essential to fall into the core measures. Having a sepsis diagnosis and clinical indication of organ dysfunction triggers SEP-1 even if no one ever documents or codes R65.20, severe sepsis.

This is because there are two ways to get a Yes value for “Was severe sepsis present?” The first is that the physician/APN/PA documents Severe Sepsis. The second is that the presence of Severe Sepsis is established by clinical criteria.

What are those criteria?

  1. The patient has an infection
  2. Two or more manifestations of systemic infection according to the general criteria for the systemic inflammatory response or SIRS (as mentioned above)
  3. Organ dysfunction

Severe sepsis was defined as “having organ dysfunction,” but SEP-1 is more prescriptive. The organ dysfunction is specified as hypotension, acute respiratory failure requiring mechanical ventilation, creatinine exceeding 2.0, low urine output, hyperbilirubinemia, thrombocytopenia, coagulopathy, or hyperlactatemia.

I would posit that waiting for hypoxia to require mechanical ventilation, or needing AKI to have a creatinine over 2, is putting the patient behind the 8-ball. Institutions that are worried about missing “early sepsis” should be concerned that the SEP-1 criteria may not be casting a wide enough net. The discussion as to whether SEP-1 is clinically valid and is improving outcomes is being tabled for a different day and forum.

My advice is for providers to use specific terminology to achieve clarity as to whether there is sepsis and to permit coders to use R65.20 which is always indicated now. My recommended macro is “sepsis due to [INFECTION] with acute sepsis-related organ dysfunction as evidenced by [LIST ORGAN DYSFUNCTION].”

Programming Note:

Listen to Dr. Erica Remer live every Tuesday on Talk Ten Tuesday, 10-10:30 a.m. EST.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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