1. Getting Sepsis
Right

2. Sepsis Affects > 1 million Americans/year
3rd leading cause of death in U.S.- kills 258,000 Americans/year, more than breast, prostate and lung cancer combined
> 700 people die each day from sepsis in U.S.
Occurs in only 10% of U.S. hospital patients but contributes to as many as 50% of all hospital deaths
U.S. spends $24 billion/year to treat sepsis
Only 10-30% of septic patients worldwide receive “excellent care” 2

3. Sepsis
80% of cases in hospitalized patients develop sepsis prior to admission
70% had recently used health services
Post-op patients are 10 times more likely to die of sepsis than PE or MI
Risk factors for post-op sepsis- age > 60, emergency surgery, co-morbidities (cancer, diabetes, hypertension, obesity) and having a co-morbidity increases risk 6X 3

4. Sepsis Most common cause of readmissions
Hospitals have difficulty diagnosing in a timely fashion, leading to treatment delays and poor outcomes
Lack of definitive test for sepsis(unlike MI, stroke) 4

5. Sepsis definitions

9. The Old Sepsis Definition (Sepsis-1)
Documented or suspected infection AND two or more of these SIRS criteria:
Temperature > 100.4O or < 96.8O F.
Pulse > 90
Respirations > 20
WBCs > 12,000 or < 4000/mm3 9

12. Other Old Related Definitions (Sepsis-1)
Severe sepsis: sepsis-induced tissue hypoperfusion or organ dysfunction
Septic shock: Hypotension that persists despite adequate fluid resuscitation 12

13. ACCP/SCCM Consensus Conference 1991 (Sepsis-1)
Sepsis = Infection + two or more SIRS criteria
Severe Sepsis = Sepsis + Organ dysfunction or hypo-perfusion
Septic Shock = Severe sepsis with persistent hypotension despite adequate fluids

14. In 2001, more detailed categories added to help clinicians recognize sepsis
Levy MM, Fink MP, Marshall JC, et al. 2001CCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.Crit Care Med 2003;31:

15. 2016
Sepsis-3
REDUNDANT
RETIRED

18. “Third International Consensus Definitions For Sepsis and Septic Shock (Sepsis-3)
Published in February 23, 2016 issue of JAMA
Society of Critical Care Medicine and European
Society of Intensive Care Medicine
"Limitations of the previous definition in 2001 included an excessive focus on inflammation, the misleading model that sepsis follows a continuum through severe sepsis to shock, and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria. Multiple definitions and terminologies are currently in use for sepsis, septic shock, and organ dysfunction, leading to discrepancies in reported incidence and observed mortality.“
Severe sepsis is now a redundant term

28. Treatment Guidelines

33. APACHE* versus SOFA scores
APACHE is severity score and mortality estimation tool specific to ICU patients with multiple disease states; uses worst values within first 24 hours of admission
SOFA is also predictive score; ongoing, specific to sepsis and uses values from first 24 hours and every 48 hours thereafter while patient is in ICU
* Acute Physiologic And Chronic Health Evaluation

34. SOFA and qSOFA
SOFA clearly requires laboratory tests and data that may not yet be available
The task force recommends clinicians use a streamlined process called quick SOFA(qSOFA) to evaluate patients outside the ICU
Altered mental status
Systolic BP < 100 mm Hg
Respirations 22 or >
If a patient meets any 2 of the qSOFA criteria the guidelines recommend the patient be closely monitored, given more intensive treatment as needed and possibly transferred to the ICU

36. IF YOU THINK THE PROBLEMS WE CREATE ARE BAD,
JUST WAIT UNTIL YOU SEE OUR SOLUTIONS.

37. CMS Sepsis Core Measure

44. Caveats for CDI/Coding- The Past
CDI versus coding wars.
Physicians often waited until patient was very ill to call the condition sepsis.
Some hospitals convinced physicians to document SIRS-positive patients as septic even though they were only in a rule-out phase. Many of those patients ended up not having sepsis but were coded as sepsis anyway even in physician indicates “rule out sepsis” in discharge summary.

45. Caveats for CDI/Coding-The Present
If physicians write sepsis in the chart now using the new definition, it will correspond with the old definition's state of severe sepsis.
Some coders may not code severe sepsis unless the physician explicitly writes 'severe.' This may lead to discrepancies in coding practice.
The SIRS criteria came out about 15 years ago, and even today CDI specialists query providers regarding SIRS. SIRS has fairly easy to remember criteria versus those of SOFA, which has six different criteria with scores ranging from 0 to 4.

46. Caveats for CDI/Coding-The Future
As more physicians embrace the new criteria, the effect on coding will be fewer reported cases of sepsis, but a greater percentage of those will be reported as severe sepsis. Hospital administrators will need to be aware that a shift in severity of illness or case mix index data may correspond to the new sepsis definition rather than to coding errors.
Now, some physicians will embrace the sepsis-3 definition while others will continue their pattern of diagnosis based on the sepsis-2 definition. Furthermore, since there will be inconsistencies in coding, that will cause billing and reporting problems. It will be difficult to compare sepsis rates from hospital to hospital and over time until there is uniformity across the country.

47. Caveats for CDI/Coding-The Future
Once new updated guidelines from CMS are provided and implemented, CDI and coding will need to be educated on what those new rules and regulations are. Query questions will need to be updated based on those guidelines as will physicians.
Hospitals will need to set a standard for validating sepsis, determine a start date to adopt the new definitions, ascertain how documentation flow will evolve and work collaboratively among physician leadership, the CDI team, and HIM to develop facility-specific definitions and establish an in-house query policy for sepsis.

48. Caveats for CDI/Coding
Inpatient quality reporting must follow specifications and guidelines for each quality measure based on predetermined bundles. If the new definition is what everyone is reporting, then quality measures and reporting will have to adjust as well. Guidance is needed from those quality programs. Abstractors will need to know what sepsis criteria to follow when reviewing documentation on hospital adherence to these measures.
The National Quality Forum measure is very clear: Hospitals will still have to expend energy according to the sepsis-2 definition and report to CMS. What will change is increased confusion for hospitals that grapple with two definitions. Physicians may use the new definitions, but the hospitals will use the old ones to report to CMS. They will have to go back to physicians to query what they meant in the record, which will be onerous and challenging for some facilities.

49. Caveats for CDI/Coding
Sepsis-3 states that patients with an infection meeting their sepsis criteria should be coded as R65.20 (severe sepsis) but this is impossible since this code in ICD-10-CM can only be assigned if physician documents “severe sepsis” not sepsis alone or if documents that acute organ dysfunction is associated with sepsis
ICD-10-CM still has multitude of codes for sepsis without organ dysfunction (A40-A41)
Must code what physician documents regardless of clinical criteria used to arrive at that diagnosis

50. Caveats for CDI/Coding
For severe sepsis, “use additional code to identify specific acute organ dysfunction”; however, if no organ dysfunction is documented or coded, RAC may say severe sepsis code is invalid
Any coding of R65.20 or R65.21 subjects record to sepsis core measure eligibility
New 2016 definitions do not currently align with CMS sepsis core measure and unknown when this will occur
SIRS due to infection was built into ICD-9 in 2001 but can’t be coded as sepsis in ICD-10-CM
Continue to code sepsis, severe sepsis and septic shock using most current version of ICD-10-CM

51. *Better intelligence

52. 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

53. 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

54. 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

55. APR Examples: 65 y/o admitted with Severe Sepsis – Note Impact of Types of Acute Renal Failure
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

56. 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: Encephalo-pathy
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

57. 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

58. 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

59. 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 altered mental status
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

60. 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

61. 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 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)

62. Graphic Portrayal

63. Your Vital Roles Public reporting-Healthgrades, Leapfrog, CMS PEPPER*
RAC audits
VBP- core measures
MD- could support higher than expected mortality and readmission rates
* Program for Evaluating Payment Patterns Electronic Report

65. Septicemia
Numerator = DRG 870 (septicemia or severe sepsis with mechanical ventilation > 96 hr)
+ 871 (septicemia or severe sepsis without mechanical ventilation > 96 hr with MCC)
+ 872 (septicemia or severe sepsis without mechanical ventilation > 96 hr without MCC)
Denominator = DRG 689 (kidney and urinary tract infections with MCC) (kidney and urinary tract infections without MCC) 65

66. Your Vital Roles
Important to correctly and appropriately identify sepsis
Research
Accuracy
Treatment
Outcomes
Core measures
BUT inappropriately querying for sepsis may incorrectly establish this diagnosis for the patient and lead to potentially deleterious results for your hospital

68. Questions ? William C. Templeton, III, MD Chief Medical Officer
Clark Memorial Hospital
Jeffersonville, IN