SEPSIS - 3 James S. Kennedy, MD, CCS, CDIP President and Chief Medical Officer CDIMD – Physician Champions Smyrna, Tennessee jkennedy@cdimd.com – (615) 479-7021

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 http://www.tinyurl.com/2016sepsis

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.

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.

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”

Sepsis Redefinition February 22, 2016

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

Endorsing Entities . . . . . .

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

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

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

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

MS-DRG 870-872 Validity Before and After Sepsis-3 Principal Diagnoses Qualifying for MS-DRG 870-872, 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