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The changing clinical indicators for sepsis have ignited a firestorm of debate at all levels of the healthcare industry. This month’s column provides a quick review of the changes and identifies three primary impacts to clinical coding as the new guidelines phase in.

Comparing sepsis indicators

The existing clinical indicators we have used for the past 20 years include identifying the presence of two or more of the following four indicators:

  • Temperature >38°C or <36°C
  • Heart rate >90/min
  • Respiratory rate >20/min or Paco2 <32 mm Hg (4.3 kPa)
  • White blood cell count >12 000/mm3 or <4000/mm3 or >10% immature bands

The new Quick SOFA (qSOFA) Sepsis 3 Criteria as published by The Journal of the American Medical Association (JAMA) in February 2016 adds “life-threatening organ dysfunction due to a dysregulated host response to infection” to the list of clinical indicators. The AMA clarifies this decision as follows:

  • The concept of non-homeostatic host response to infection is stressed while the SIRS criteria have been removed.
  • The inflammatory response accompanying infection (pyrexia, neutrophilia, etc.) often represents an appropriate host response to any infection, and may not necessarily be life-threatening.

Due to the additional criterion for sepsis, there is misalignment between the existing clinical coding guidelines for sepsis and the new clinical indicators. Today, sepsis can be coded with or without organ dysfunction, as sepsis or major sepsis respectively, in which both are considered an MCC. With the new criteria from JAMA, organ dysfunction must be present for a sepsis diagnosis.

Three hurdles for clinical coding

Sepsis coding guidelines have been vetted and well-defined over the years. Each healthcare system has established guidelines based on the long-standing definitions, Official Coding Guidelines, and internal medical staff approvals. The new indicators released by JAMA do not match current sepsis coding guidelines: herein lies the issue for coding teams.

Once the new Sepsis 3 indicators are reviewed and approved by each organization’s medical staff, it is the responsibility of HIM and CDI leadership to analyze coding guidelines in terms of the new criteria. There are three primary categories to be aware of with this change:

  1. Line up coding guidelines to match with the new definition. This is an arduous process that must begin with national updates to established coding guidelines. Each organization can also take the lead internally by reviewing JAMA’s indicators and making an internal decision to update their internal coding guidelines accordingly. Working in conjunction with their medical staff, all CDI, coding teams, and medical staff must be on the same page with new definitions and when the shift will occur.
  2. Educate coders on the new definition, updated coding guidelines and how coding protocols will change. A structured, intentional education program makes sense to accomplish this goal (suggestions are below). 
  3. Understand the denial impact of timing differences between providers and payers. In all likelihood, payers will start using the new guidelines before we, as coders, have started updating the guidelines. So at the health system level, there must be clear leadership and a defined protocol to realign the sepsis coding guidelines.

A critical question that must be addressed: Who is going to switch the coding guidelines?

Updating your sepsis clinical coding guidelines

In order to get ahead of a solution, physicians, infectious disease specialists, HIM, revenue cycle, CDI, compliance, and coding should ALL be having conversations about these changes and the three impacts mentioned above.

At a recent ACDIS conference “Special Panel Session: New Sepsis Definition”, two physician panel sessions were held to review the new criteria and explore best practices for adoption and implementation. The findings presented at this conference, held in Atlanta in May 2016, delved into some of the coding implications arising from this new definition. Five key points of concern were reiterated during the presentation:

  • Sepsis 3 states that “the term severe sepsis was redundant” indicating that sepsis without organ dysfunction does not exist.
  • The Sepsis 3 definitions are inconsistent with the ICD-10-CM Official Guidelines for Coding and Reporting (OCG), which distinguishes between sepsis without organ dysfunction and sepsis with organ dysfunction.
  • Sepsis 3 makes erroneous recommendations for the “primary” codes to be used pursuant to the new definitions.
  • The OCG and ICD-10-CM do not require organ dysfunction be specified as “due to” sepsis for assignment of R65.20 (severe sepsis), but having this documentation makes the connection indisputable.

The panel reiterated that according to Sepsis 3, sepsis cannot be a value diagnosis without organ dysfunction caused by infection.

Click here to view the full slide deck from the panel.

Begin with awareness

The best approach to address coding impacts for sepsis head-on is through awareness and education.

  • Begin by awareness through bulletins and written materials.
  • Build knowledge through online education portals, lunch-and-learns, and internal webinars.
  • Practice the new skill set by using coding training systems and tools.

Using a proactive approach, the coding industry can respond to the new sepsis changes, educate teams, and train on the new protocols before payer denials occur.


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