1. Sepsis – Impact of Coding upon Metrics

2. Sepsis – Impact of Coding upon Metrics
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, CDI
Sutter West Bay
San Francisco, CA

3. Agenda WHY Care About Coding? WHAT is Required for Accurate Data?
HOW is Sepsis Coded?
Impact of Key Terms Upon Data (ROM)
Documentation “Tips” for Sepsis

4. Why Care About Coding?
Accuracy of severity and predicted mortality – factors are adjusted for risk using coding
• Public Reporting
Coder - Function as compliant translator to compliantly and accurately report data – subject to many restrictive conventions and audits

5. Data Trends Financial Consumers Pay for Performance
3rd parties use coded data for reimbursement, audits and compliance
Consumers
Healthgrades – Leapfrog – State Organizations – CMS
Pay for Performance
RAC, Value-Based Purchasing, Never Events

6. Why Does Data Matter? (Hospital and physician profiling data is available to the public)
Coded Data used to report to increasing number of 3rd parties – private and public

7. Graphic Portrayal

8. Public Websites on Outcomes – Coding Used to Report Outcomes

9. Increased Physician Scrutiny
Without all factoring conditions documented, profiles will inappropriately reflect higher than expected mortality
• Complete documentation, reflective of the true severity of your patients, helps justify outcomes
Profiles are used for both commercial and public use - Future reimbursement methods will likely incorporate profiles in the formula (pay for performance)
Example: A patient expiring on ICU with urosepsis, acute renal disease and hypotension will be ‘underrepresented’ in terms of SOI/ROM

10. Formulas for Sepsis = MD & Facility Scores
Combined mortality for Severe Sepsis (ICD ) and Septic Shock (785.52)
(Number of expired severe sepsis patients + Number of expired septic shock patients) / (Number of severe sepsis cases + Number of septic shock cases).
Ratio of Observed to Expected Mortality for Septicemia & Disseminated Infections (APR-DRG 720)
Number of observed expired septicemia & disseminated infection patients / Number of expected expired septicemia & disseminated infection patients. IMPACTED BY – Coding of Septic Patients

11. Sepsis Coding “Formula”
Note the codes for Severe Sepsis and Septic Shock must be applied in order for accurate reporting of outcomes
The coding is driven by very explicit clinical documentation of discharges noted ‘at the time of discharge’
It is possible that Severe Sepsis with Shock will be treated, and the Bundles will be completed, but cases will not be in the study due to coding issues?
Persistent hypotension with pressors is not coded to septic shock – in this scenario, will patient be placed in correct ‘bucket’ for bundle complaince?

12. Problematic Terms Urosepsis, Bacteremia, Pneumonia & Hypotension:
= Severe Sepsis or Septic Shock!
Severe Sepsis with Multi-Organ Failure – Explicitly document the specific organ failure

13. The AHRQ Quality Indicators and the APR-DRGs
The APR DRGs - used by Agency for Healthcare Research and Quality (AHRQ) for risk adjustment to the Inpatient Quality Indicators (IQI)
The IQI - indicators of inpatient mortality for selected procedures and conditions.
APR-DRG Methodology universally accepted to report risk-adjusted ROM across many quality organizations

14. APR-DRG – Gold Standard for Risk-Adjusted Outcomes Data
The determination of the severity of illness and risk of mortality is disease-specific (Different ROM for patient admitted with Acute Exacerbation of Asthma, Simple or Complex PNA, CVA, Sepsis, so forth)
How do we achieve a high score? Should we always expect a high score (no) – Young male admitted with simple PNA will have low acuity. Older patient admitted with gram-negative or asp pna with acute renal or respiratory failure or underlying chronic conditions, such as Type I DM or AIDS or CM will have higher level of acuity. The ‘presenting problem’ and presence of 2ndry factors both important factors.

15. APR-DRG – Gold Standard for Risk-Adjusted Outcomes Data
In APR DRGs, high severity of illness or risk of mortality are primarily determined by the interaction of multiple diseases
Patients with multiple comorbid conditions involving multiple organ systems represent difficult-to-treat patients who tend to have poor outcomes

16. Uses of APR-DRG To quantify demographic and clinical risk factors.
Comparisons between disparate populations or groups.
Clinical outcomes
Mortality
Complications
Utilization measures
Length of Stay
Cost

17. APR-DRG – Structure
Set of patient groups (APR-DRGs) that include adjustments for Severity of Illness (SOI) and Risk of Mortality (ROM)
The groups are designed to describe the complete cross-section of patients seen in acute care hospitals
Four subclasses (Grade 1 -4) for both SOI & ROM
Clinical model that has been extensively refined with historical data from all payers and the logic is open to users.

18. System Generates SOI/ROM for All Acute Admissions
Four Severity of Illness Subclasses
Minor
Moderate
Major
Extreme
Physiologic decompensation or
organ system loss of function
Four Risk of Mortality Subclasses
Minor
Moderate
Major
Extreme
Likelihood of dying
ROM Drives Observed/Expected Mortality Data = compiled data. Some payers now pay on SOI rather than MS-DRG

19. APR Examples: 65 y/o admitted with Severe Sepsis – Note Impact of Types of ARF
Option 1
Option 2
Option 3
Option 4
Option 5
Severe Sepsis
SDx: None
SDx: ATN
SDx: Acute Cortical Necrosis
SDx: Acute Medullary Necrosis
SDx: ARF, Not Specified
SOI : 1
SOI : 3
SOI : 2
ROM: 1
ROM: 3
ROM: 2
Problems - Abbreviations, Insufficiency, Azotemia, Cr levels noted as abnormal w/o statement of renal dysfunction

20. Note Impact of Other Organ Failure
Option 1
Option 2
Option 3
Option 4
Option 5
Severe Sepsis
SDx: Critical Illness Myopathy
SDx: DIC
SDx: Encephalopathy
SDx: Shock Liver
SDx: Septic Shock
SOI : 3
SOI : 2
ROM: 2
ROM: 3
Impact of Other Single Organ Failures 2/2 Severe Sepsis is Illustrated

21. Impact of Multiple Organ Failures on SOI/ROM
Option 1
Option 2
Option 3
Option 4
Severe Sepsis
SDx: UTI
SDx: UTI & (ADD) Septic Shock
SDx: UTI & Septic Shock & (ADD) Acute Renal Failure
SDx: UTI & Septic Shock & Acute Renal Failure (ADD DIC)
SOI : 1
SOI : 2
SOI : 3
SOI : 4
ROM: 2
ROM : 3
ROM: 4
Notice how ROM/SOI elevate when multiple body systems are affected – increased clinical complexity and mgmt = higher scores

22. Clinically Significant but Low SOI:
Lower to Greater SOI
Clinically Significant but Low SOI:
Greater SOI Captured:
Severe Hypoxia (S&S)
Urosepsis
Uncontrolled NIDDM
Severe COPD on continuous O2
Community Acquired Pneumonia and dysphasia, s/p CVA.
Serum Na of 145 mEq/L
Early or mild Acute Respiratory Failure
UTI with Sepsis
Type 2 DM with Hyperosmolarity, uncontrolled.
Chronic Respiratory Failure
Possible Aspiration Pneumonia - Community Acquired
Hypernatremia
Common coding conundrums – our facility has MD-Approved and evidence-based query forms for each because these are high-volume scenarios

23. Examples: Documenting Consequences of Sepsis
Acute Kidney Failure - not insufficiency
Acute Respiratory Failure – not hypoxia
Critical Illness Myopathy – not weakness
DIC – not coagulopathy
Encephalopathy – not AMS
Acute Hepatic Failure – Not Elevated Liver Enzymes
Septic Shock – not hypotension
State ALL manifestations of Sepsis in the Discharge Diagnosis!
This language is directly and compliantly coded

24. Importance of Reliable Documentation: Best Place = Discharge Summary
Discharge summary documents all significant conditions
Discharge summary must be consistent with documentation in the body of the record. If not, query the physician
Gold Standard = D/C Summary - Attending Documentation carries great weight

25. Discharge Documentation - Example
The summary should clarify if conditions were present on admission and have resolved, are still to be ruled out, or were in fact ruled out.
Admission note: “Sepsis with Septic Shock secondary to Pneumonia.”
Progress note: “Sepsis, and Shock improving.”
Discharge summary: “Sepsis, Septic Shock and pneumonia, resolved”

26. Coding – Brief Notes Bacterial Sepsis and Septicemia
In most cases, it will be a code from category 038, Septicemia, that will be used in conjunction with a code from subcategory such as the following:
Streptococcal sepsis If the documentation in the record states streptococcal sepsis, codes 038.0, Streptococcal septicemia, and code should be used, in that sequence.
Streptococcal septicemia If the documentation states streptococcal septicemia, only code should be assigned, however, the provider should be queried whether the patient has sepsis, an infection with SIRS

27. Coding – Brief Notes
Sepsis or severe sepsis may be present on admission, but the diagnosis may not be confirmed until sometime after admission
If the documentation is not (crystal) clear whether the sepsis or severe sepsis was present on admission, the provider should be queried
May have quality implications

28. Special Note – Comfort Care
Document reasons for “Comfort Care”
All patients factor into the MD personal O/E (Outcomes) data and the facility O/E (Outcomes) Data
Provide Example: ICH with Midline Shift versus with hernia of brain - Severe Sepsis - Multiple Trauma with Shock due to Hemorrhage

29. Query??
A coder or other concurrent reviewer may ‘query’ a clinician regarding Severe Sepsis if certain conditions are present and the condition is not stated (or, sepsis IS stated, but not ‘supported’ by clinical indicators)
AHIMA released “Guidelines for Achieving a Compliant Query Practice,” in the February 2013 edition of the Journal of AHIMA. The document, created in collaboration with ACDIS volunteers and approved by the ACDIS Advisory Board, states that coding (or CDI) staff should query the physician if a diagnosis is not supported by clinical indicator(s) in the medical record

30. Query??
“The focus of external audits has expanded in recent years to include clinical validation review. The Centers for Medicare and Medicaid Services (CMS) has instructed coders to ‘refer to the Coding Clinic guidelines and query the physician when clinical validation is required.’ The practitioner does not have to use the criteria specifically outlined by Coding Clinic, but reasonable support within the health record for the diagnosis must be present. When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy”
Source: AHIMA Practice Brief Guidelines for Achieving a Compliant Query Practice

31. Query??
The generation of a query should be considered when the health record documentation:
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

32. Query?? Best Practice for Facility Accredited Coders/CDI Staff
Linkage to Physician Advisors & Quality Staff
Facility formulation, to the ‘extent possible’ of evidence-based and physician approved definitions for major/key conditions – AMI, ARF, Sepsis, Septic Shock, Acute Respiratory Failure, CHF
Define, Document, Defend using approved definitions
Support Quality Measures and generate ACCURATE coding to support risk-adjusted outcomes data

33. Sample Study – Why is O/E Not on Par?
ROM and O/E Trended Data for APR-DRG 720: Note. The Site Mortality Data exceeds CDB in ROM 3 & 4. Also note the O/E = 1.28
Also, note the data reflects Septic Cases with ROM scores of “1” exceeding the norm.

34. Data Mining
Ensure all expired cases with low scores (2 or less) are reviewed systematically by clinician and coder prior to final coding
Review APR/DRG 720 for ROM/SOI Scores
Review cases with code assignment for : Severe Sepsis – with a ROM of ‘2’ or less (995.92, Severe Sepsis) implies an organ failure – the ROM is could be greater than ‘2’ when certain organ failure or combinations is/are reported with Severe Sepsis
Review cases with major infections that ARE NOT coded to Sepsis – Did these meet the SIRS Criteria and are not coded to Sepsis?
Examples, patients with Pneumonia, SBP, Cholangitis – focus on those with high charges and/or extended LOS (GMLOS per MS-DRG Methodology)

35. Questions?