2. Challenges in critical care: Sepsis and respiratory failure
William Haik, MD
Director, DRG Review, Inc.

3. Challenges in critical care: Respiratory failure

4. Acute respiratory failure Criteria
Inadequate exchange of oxygen and/or carbon dioxide by the lungs
Life-threatening disorder requiring aggressive management and monitoring
Evidence of increased work of breathing or possibly cyanosis and/or paradoxical breathing
Absence of mechanical ventilation does not exclude the diagnosis of acute respiratory failure 4

5. Acute respiratory failure ABGs
A patient with acute respiratory failure with previously normal lungs:
PO2 <60 mmHg, PCO2 >50 mmHg
Acute respiratory failure in a patient with previously abnormal lungs, such as chronic obstructive lung disease:
pH <7.35 with a PCO2 >50 mmHg OR
A change in the PO2 <60 mmHg, representing a drop of 15 mm Hg from the previous "normal" PO2 5

6. Acute respiratory failure (Treatment)
Oxygen monitoring and support
Respiratory support (CPAP, BiPAP, mechanical ventilation)
Treatment of underlying condition

7. Chronic respiratory failure ABGs
PO2 <55-60 mmHg / HBSat <90% OR
pH >7.35 <7.38 with PCO2 >40 mmHg 7

8. Sequencing acute respiratory failure
Consider reporting acute respiratory failure as a principal diagnosis (“that condition established after study chiefly responsible for occasioning the admission of the patient to the hospital for care”) in the following circumstance:
If respiratory failure is associated with another acute condition that is equally responsible for occasioning the patient’s admission to the hospital, and there are no chapter-specific sequencing rules (see below), the guideline regarding two or more diagnoses which equally meet the definition of principal diagnosis may be applied in this situation.
Example: Acute respiratory failure secondary to aspiration pneumonia. Either acute condition may be sequenced as the principal diagnosis depending on the circumstances of admission.
Example: Acute respiratory failure secondary to cardiogenic pulmonary edema in a patient with an acute, anterior wall myocardial infarction. Either acute condition may be sequenced as the principal diagnosis depending on the circumstances of admission.

9. Sequencing acute respiratory failure
When acute respiratory failure is an adverse reaction to a drug, follow the coding rule for coding an adverse drug reaction sequencing respiratory failure first, followed by the appropriate external cause code for the drug (E code).
Example: Respiratory failure secondary to aspirin taken as prescribed.
Respiratory failure is the principal diagnosis.
When the cause of the respiratory failure is not identified. This may occur when the patient expires or is transferred shortly after admission.

10. Sequencing acute respiratory failure
Do not code acute respiratory failure as the principal diagnosis when there is a chapter-specific coding guideline (sepsis, obstetrics, poisoning, HIV, newborn) or an alphabetic index or tabular directive which takes precedence over the general respiratory failure guidelines and examples listed above.
Example: Acute respiratory failure, secondary to Pneumocystis carinii pneumonia in a patient with HIV. The human immunodeficiency virus (042) is reported as the principal diagnosis.
Example: A patient is admitted with acute respiratory failure secondary to Valium overdose. The poisoning (Valium overdose) is reported as the principal diagnosis.
Example: A patient is admitted with aspiration pneumonia with associated sepsis and acute respiratory failure. Sepsis is reported as the principal diagnosis.

11. Acute respiratory failure References
AHA’s Coding Clinic for ICD-9-CM, Volume 5, Number 3, Third Quarter, 1988, p. 7.
AHA’s Coding Clinic for ICD-9-CM, Second Quarter, 1990, pp. 20–21.
AHA’s Coding Clinic for ICD-9-CM, First Quarter, 2005, pp. 3–8.
AHA’s Coding Clinic for ICD-9-CM, Second Quarter, 2005, pp. 19–20.
AHA’s Coding Clinic for ICD-9-CM, First Quarter, 2008, pp.18–19.
AHA’s Coding Clinic for ICD-9-CM, Fourth Quarter, 2008, p. 245.

12. Do not query for acute respiratory failure …
If PO2 >50 mmHg on room air or pH >7.35
If there is no evidence of increased work of breathing (unless the patient is obtunded)
If there is no aggressive treatment or monitoring provided (unless the patient is DNR)

13. Acute respiratory failure (Sample query)
Dear Dr :
Can the documentation of ________ (respiratory insufficiency, respiratory distress, hypoxia) in the ________ (H&P, progress notes, pulmonary consult, other) be further specified as:
Acute respiratory failure _________________ ________
Signature Date
Acute on chronic respiratory failure _________________ ________
Undetermined _________________ ________
Signature Date
Other _________ _________________ ________
Reason for query:
It is noted in the ________ (H&P, progress notes, pulmonary consult, other) the patient is described as having increased work of breathing as evidenced by _____ (RR > 20, accessory muscle use, other) with evidence of inadequate gas exchange _____ (PO2 <50 mm Hg, pH <7.35 with PCO2 >40 mmHg, cyanosis). Additionally, the patient is admitted to a monitored unit and treated aggressively with _____ (increased bronchodilator treatment, O2 support, CPAP, BiPAP, mechanical ventilation).
Therefore, to accurately reflect the severity of the patient's illness, can the condition be further specified?
Please document your response in the discharge summary, final progress note, or as listed above (signed and dated).
_________________________________________________ ________
Documentation Improvement Specialist/Coding Department Date

14. Challenges in critical care: Sepsis

15. SEPSIS SIRS Bacteremia Severe sepsis Urosepsis Sepsis syndrome
Septicemia

16. Infection
Infection: invasion of normally sterile tissue, fluid, or body cavity by pathogenic microorganisms

17. Bacteremia
Bacteremia: 790.7, a laboratory finding of viable bacteria in the blood without evidence of a systemic inflammatory response

18. Systemic Inflammatory Response Syndrome (SIRS)
Systemic Inflammatory Response Syndrome (SIRS): , a syndrome defined by the presence of two or more of the following features of systemic inflammation:
Fever (oral temperature > 38°C or 100.4°F) or Hypothermia (oral temperature < 36°C or 96.8°F)
Leukocytosis (white count > 12,000) or Leukopenia (white count < 4,000 or > 10% bands)
Tachycardia (> 90 beats per minute)
Tachypnea (respiratory rate > 20 breaths per minute or a pCO2 of < 32 mm Hg)

19. Sepsis
Sepsis: , is synonymous with SIRS due to infection without organ dysfunction. This is an infection-induced syndrome defined since 2003 to include the presence of multiple features of systemic inflammation:
SIRS criteria (as per previous slide)
Altered mental status
Oliguria (<30 ccs per hour)
Hypotension (systolic blood pressure <90 mmHg or a 40 mmHg drop from the previous normal blood pressure responsive to fluid resuscitation)
Evidence of hypoperfusion (increase anion gap, reduced arterial pH, elevated lactate level, and reduced skin perfusion)
Elevated biomarkers (C-reactive protein, procalcitonin, Interleukin-6)

20. Septicemia
Septicemia: 038.x, is an antiquated, ambiguous term which has been used nonspecifically in the past to imply either bacteremia or sepsis; therefore, should be eliminated from current medical usage

21. Severe sepsis
Severe sepsis: , (sometimes referred to as sepsis syndrome) is synonymous with SIRS due to infection with organ dysfunction. This condition occurs when sepsis overwhelms the counterregulatory control mechanisms, resulting in organ dysfunction. This is typified as:
Acute renal failure (creatinine > 2 x ULN or baseline)
ARDS (PaO2/FiO2 < 250)
DIC (thrombocytopenia—platelet count <100,000)
Encephalopathy
Hepatic failure (bilirubin or SGOT > 2 x ULN)

22. Septic shock
Septic shock, , is severe sepsis with hypotension (systolic blood pressure <90 mmHg or a 40 mmHg drop from the previous normal blood pressure) unresponsive to fluid resuscitation, requiring vasopressor intervention
When physicians document septicemia with shock or sepsis with septic shock, then the correct code assignment is 038.9/995.92/ and a code for the underlying infection.

23. Common sequencing concerns regarding SIRS/sepsis/severe sepsis
1. The underlying cause (such as infection or trauma) is sequenced before any code from series, systemic inflammatory response syndrome (SIRS).
Reference: AHA’s Coding Clinic for ICD-9-CM, Fourth Quarter, 2008, p. 14.
2. If sepsis (995.91) or severe sepsis (995.92) meets the definition of principal diagnosis, the systemic infection code (such as 038.xx) should be assigned as the principal diagnosis, followed by sepsis or severe sepsis. The localized infection (such as a urinary tract infection, 599.0) should be reported as an additional diagnosis.
Reference: AHA’s Coding Clinic for ICD-9-CM, Fourth Quarter, 2008, p. 15.
3. When the admission is for treatment of a complication resulting from surgical or medical care, the complication code ( ) is sequenced as the principal diagnosis, followed by the appropriate sepsis codes.
Reference: AHA’s Coding Clinic for ICD-9-CM, Second Quarter, 2005, pp.19–20.
Reference: AHA’s Coding Clinic for ICD-9-CM, Fourth Quarter, 2008, p. 218.
Reference: AHA’s Coding Clinic for ICD-9-CM, Fourth Quarter, 2008, p. 303.

24. Sepsis references
Bone, R.C., ACCP/SCCM Consensus Conference, Chest, 1992;101:1044–55.
Levy, M.M., International Sepsis Definition Conference, 2001, Critical Care Medicine, 2003;31:1250–1256.
AHA’s Coding Clinic for ICD-9-CM, First Quarter 1988, pp. 1, 3.
AHA’s Coding Clinic for ICD-9-CM, Third Quarter 1988, p. 12.
AHA’s Coding Clinic for ICD-9-CM, First Quarter 1998, p. 5.
AHA’s Coding Clinic for ICD-9-CM, Third Quarter 1999, pp. 5–6.
AHA’s Coding Clinic for ICD-9-CM, Second Quarter, 2000, pp. 3–7.
AHA’s Coding Clinic for ICD-9-CM, Second Quarter, 2005, pp.19–20.
AHA’s Coding Clinic for ICD-9-CM, Fourth Quarter, 2008, pp. 213–218.

25. Do not query for sepsis …
If few findings of SIRS/sepsis
If based solely on positive blood culture or increased white blood cell count

26. Physician query for urosepsis
Dear Dr :
Since “urosepsis” is a nonspecific entity for coding purposes, based on the multiple clinical elements documented in the record (as circled), can you further specify as:
Urinary tract infection ___________________ ________
Signature Date
Sepsis ___________________ ________
Severe sepsis from a urinary source ___________________ ________
Undetermined ____________________ ________
Other __________ ____________________ ________

27. Physician query for urosepsis
Documentation for sepsis:
a. Fever (oral temperature > 38°C or 100.4°F) or Hypothermia (oral temperature < 36°C or 96.8°F)
b. Leukocytosis (white count > 12,000) or Leukopenia (white count < 4,000 or > 10% bands)
c. Tachycardia (> 90 beats per minute)
d. Tachypnea (respiratory rate > 20 breaths per minute or a pCO2 of < 32 mm Hg)
e. Altered mental status
f. Oliguria (<30 ccs per hour)
g. Hypotension (systolic blood pressure <90 mmHg or a 40 mmHg drop from the previous normal blood pressure responding to fluid resuscitation)
h. Evidence of hypoperfusion (increase anion gap, reduced arterial pH, elevated lactate level, and reduced skin perfusion)
i. Elevated biomarkers (C-reactive protein, procalcitonin, Interleukin-6)
2. Documentation for severe sepsis (sometimes referred to as sepsis syndrome):
a. Acute renal failure (creatinine > 2 x ULN or baseline)
b. ARDS (PaO2/FiO2 < 250)
c. DIC (thrombocytopenia—platelet count <100,000)
d. Encephalopathy
e. Hepatic failure (bilirubin or SGOT > 2 x ULN)

28. Physician query for urosepsis (continued)
3. Appropriate treatment for sepsis/severe sepsis:
a. Broad spectrum antibiotics
b. IV fluid resuscitation
c. Vasopressor therapy (such as with Dopamine)
d. Clotting factors or platelet transfusions
e. Xigris infusion
4. Please document your response either in the final progress note or discharge summary.
Therefore, to accurately reflect the severity of the patient's illness, can the condition be further specified?
Please document your response in the discharge summary, final progress note, or as listed above (signed and dated).
_________________________________________________ ________
Documentation Improvement Specialist/Coding Department Date

29. Questions?