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Payment and reimbursement are important
as well.
Accurate medical coding helps to make certain a healthcare organization offers the best possible uninterrupted care. Medical data, quality review, and other relevant information needed to assist in the patient’s care require medical coding to be as complete and accurate as possible. Although patient-centered care should be the number one focus of any healthcare provider; there is another reason medical coding should be complete and accurate. The healthcare organization’s payment and physician’s reimbursement are important as well. Hospitals are being faced with more and more costly audit denials by entities such as Recovery Audit Contractors (RAC). RACs have audited Medicare claims since 2010. Sepsis and sepsis-related claims have been at the top of their list of audits. Medical claims are being denied and/or underpaid for reasons such as poor documentation and improperly applying the guidelines (especially sequencing guidelines) during the coding process. An example of poor documentation is when a patient has “bacteremia,” “sepsis,” and “urosepsis” documented throughout the medical record and in the discharge summary only “urosepsis” is documented. In provider documentation, the term “urosepsis” is oftentimes used interchangeably to mean a urinary tract infection (UTI) or sepsis. On the other hand, for the purpose of ICD-10 CM coding the term “urosepsis” is not used. The physician should be queried for further clarification to prevent claim denial. An example of improper sequencing occurs when septicemia due to an UTI documented as due to an indwelling urinary catheter is sequenced with septicemia as the principal diagnosis. The code for “complication of the urinary catheter” in both ICD-9 CM and ICD-10 CM, “complication of the urinary catheter” should be the principal diagnosis rather than the code for the sepsis. If the sepsis is submitted as the principal diagnosis the reimbursement would be less than if the proper sequencing guideline had been used which makes “complication of the urinary catheter” the principal diagnosis.
WHY IS IT SO IMPORTANT TO GET IT RIGHT?
WHAT TO EXPECT
1 Why Is It So Important to
Get It Right?
2 What Should We
Remember?
3 Guidelines
4 Requests for Coding Topics
March 2015
Volume 2 Issue 3
By Cynthia Brown, MBA, RHIT, CCS
www.cyntcodinghealthinformationservices.com
CCHIS, P.O. Box 3019, Decatur, GA 30031 404-992-8984 http://www.cyntcodinghealth informationserv ices.com Cynth ia@cyntcodinghealthinformat ionserv ices.com [phone]
CODING YESTERDAY’S NOMENCLATURE TODAY®
SEPTICEMIA, SYSTEMIC INFLAMMATORY RESPONSE
SYNDROME (SIRS), SEPSIS, SEVERE SEPSIS & SEPTIC SHOCK,
ICD-9 CM & ICD-10 CM CODING PART II
CODING NEWSLETTER FOR HEALTHCARE
CODING PROFESSIONALS
Page 2 Coding Yesterday’s Nomenclature Today
Physician documentation is the key to proper code assignment and should:
Distinguish between septicemia, bacteremia, urosepsis, sepsis, systemic/local infections, severe sepsis, and septic shock
Show a link between sepsis and the underlying infection Show a link between severe sepsis, septic shock and organ failure(s)
Documentation should include hypotension or organ failure (dysfunction) Specify whether sepsis (SIRS) is due to an infectious or non-infectious
condition. Sequencing is also a major factor in correct code assignment. The coder should use the following to determine the principal diagnosis:
Whether SIRS is due to an infectious or non-infectious condition Whether the non-infectious condition leads to infection and sepsis Whether sepsis or non-infectious condition is present on admission (POA) Whether sepsis is due to the presence of a device or is due to a
postoperative procedure In the inpatient setting there are common MS-DRGs in both ICD-9 CM and ICD-10 CM which may prompt an audit:
Knowing the difference between a systemic infection and a local infection is important. Systemic infections affect the entire body or an entire system in the body. Localized infections are in a single location and are usually cellulitis of the skin, pneumonia, or a bladder infection. Don’t forget that common localized infections like pneumonia, UTIs, appendicitis, infections from cuts, and skin infections can become systemic.
www.cyntcodinghealthinformationservices.com
MSG-DRG 870 Sepsis w/mechanical vent 96+ hr
MSG-DRG 871 Sepsis w/o mechanical vent 96+ hr w/MCC
MSG-DRG 872 Sepsis w/o mechanical vent 96+ hr w/o MCC
“Not sure…then Query the
Physician”
Physician
documentation is the
key
What Should We Remember?
Coding Yesterday’s Nomenclature Today
GUIDELINES ICD-9 CM ICD-10 CM
Sepsis and severe sepsis require a
code for the systemic infection
(038.xx, 112.5, etc.) and either
code 995.91, Sepsis, or 995.92,
Severe sepsis. If the causal
organism is not documented, assign
code 038.9, Unspecified
septicemia.
For a diagnosis of sepsis, assign the
appropriate code for the underlying
systemic infection. If the type of
infection or causal organism is not
further specified, assign code
A41.9, Sepsis, unspecified
organism.
Severe sepsis requires additional
code(s) for the associated acute
organ dysfunction(s). If a patient
has sepsis with multiple organ
dysfunctions, follow the
instructions for coding severe
sepsis. Either the term sepsis or
SIRS must be documented to
assign a code from subcategory
995.9.
A code from subcategory R65.2,
Severe sepsis, should not be
assigned unless severe sepsis or an
associated acute organ dysfunction
is documented.
If a patient has sepsis and an acute
organ dysfunction, but the medical
record documentation indicates that
the acute organ dysfunction is
related to a medical condition other
than the sepsis, do not assign code
995.92, Severe sepsis.
If a patient has sepsis and an acute
organ dysfunction, but the medical
record documentation indicates that
the acute organ dysfunction is
related to a medical condition other
than the sepsis, do not assign a
code from subcategory R65.2,
Severe sepsis.
Negative and inclusive blood
cultures do not preclude a diagnosis
of sepsis in patients with clinical
evidence of the condition; however,
the provider should be queried.
Negative and inclusive blood
cultures do not preclude a diagnosis
of sepsis in patients with clinical
evidence of the condition; however,
the provider should be queried.
If sepsis or severe sepsis is
documented as associated with a
non-infectious condition, such as a
burn or serious injury, and this
condition meets the definition for
principal diagnosis, the code for the
non-infectious condition should be
sequenced first, followed by the
code for the systemic infection and
either code 995.91, Sepsis, or
995.92, Severe sepsis.
If sepsis or severe sepsis is
documented as associated with a
noninfectious condition, such as a
burn or serious injury, and this
condition meets the definition for
principal diagnosis, the code for the
noninfectious condition should be
sequenced first, followed by the
code for the resulting infection.
www.cyntcodinghealthinformationservices.com
AHIMA approved ICD-10 CM/PCS
Trainer
ALL THINGS CODING®
“Accurate and
complete coding is a
must in today’s
economically
challenged healthcare
environment.”
Page 4 Coding Yesterday’s Nomenclature Today
CCHIS Professional Affiliates
AHIMA GHIMA AHIMA approved ICD-10 CM/PCS
Trainer EDWOSB/WOSB VOSB SCORE Atlanta
CyntCoding Health Information Services P.O. BOX 3019 Decatur, GA 30031
Phone: 404-992-8984
E-Fax: 678-805-4919
E-mail: [email protected]
Requests for coding topics: E-mail your coding topics or request your FREE issue of the CCHIS Newsletter by visiting the website and leaving your contact information. You may also contact me at: [email protected].
CODING YESTERDAY’S NOMENCLATURE TODAY TERMS AND CONDITIONS OF USE
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