1. SEPSIS - 3 James S. Kennedy, MD, CCS, CDIP
President and Chief Medical Officer
CDIMD – Physician Champions
Smyrna, Tennessee
– (615)

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. 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.

4. 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.

5. 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”

6. Sepsis Redefinition February 22, 2016

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

8. Endorsing Entities . . . . . .

9. 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

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

11. 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

12. 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

13. 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