Guest Post: Complying with definition changes, part 3

by James S. Kennedy, MD, CCS, CDIP

Note: This post is part three of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.

For those who have been reading along with my columns regarding sepsis documentation and coding challenges, allow me to suggest the following strategies to assure a balance of compliance :

• Standardize the definition and documentation of severe sepsis first.Recovery Auditors (RAs) will be looking for records with sepsis codes that do not have R65.20 or R65.21 as a secondary diagnosis as to deny these codes and DRGs. So CDI specialists should work with medical staff to establish standardized definitions; this could incorporate any or all of the following three criteria:
  1. Change in SOFA score of 2 or more, which means that a new PaO2 of <60 on room air, or a Glasgow Coma Scale of 13 could, by themselves, generate the two points needed to qualify for an acute organ dysfunction. The physician would have to document what the organ dysfunction is, which may not necessarily be an organ failure, given that ICD-10-CM uses the word “dysfunction” rather than “failure” in justifying R65.20, severe sepsis. I suggest this be part of a standardized emergency department assessment template or admission order involving an infection, which means we must reprogram our electronic health record (Epic, Cerner, Meditech, McKesson) to systematize their capture.
  2. A lactate level of 2 mEq/L or more due to an infection. If the coder requires an organ dysfunction to go with R65.20, the physician would have to document tissue hypoperfusion for which no ICD-10-CM code is in the index to diseases. I suggest coding I99.8, other disorder of circulatory system.
  3. Any of the criteria described in SEP-1 (which can include a lactate level of 4 mEq/L or more to define septic shock). Note that SEP-1 documentation or order templates must be reviewed in light of what is needed for ICD-10-CM, given that these are signed by a provider, they may be used for coding purposes.

No matter what criteria you use, be sure to coordinate it with your quality and CDI/coding staff so if a physician documents “severe sepsis” or “septic shock,” the SEP-1 algorithm can be implemented. Also, be sure that physicians explicitly link organ dysfunctions to sepsis or preferably use the word “severe sepsis” so R65.20 is not inadvertently missed by the coders. As mentioned above, coders and CDI specialists should work closely with quality to ascertain if any of these organ dysfunctions in the setting of sepsis represent severe sepsis prior to claim submission. Here are my suggestions as to how to handle the current situation:

1. Develop a facility-wide definition for sepsis without organ dysfunction. As you see above, many physicians in the United States do not believe that organ dysfunction is required to diagnose a patient with sepsis. Given that RAs are likely to use Sepsis-3 as a foundation for denying claims, you must have the statements of your internal medicine, critical care, and other physician committees as to what the definition of sepsis is for clinical and coding purposes so that when it is documented by a provider, this statement can be used to disprove the RA’s denials. These will be handy if you are appealing beyond the first level.
2. Remind the RA that the ICD-10-CM guidelines is part of HIPAA and that coding is based on provider documentation, not the RA’s interpretation. I’m sure that all of our contracts with private-payers state that we will comply with federal law, such as HIPAA. Given that the 2017 ICD-10-CM Official Guidelines state that we are to assign ICD-10-CM codes based on provider documentation and that Coding Clinic, First Quarter 2014, pp. 16-17, states that “the official guidelines are part of the HIPAA code set standards.” We don’t want RAs to violate HIPAA or our contracts with payers, do we? This may require that a hospital attorney or compliance officer weigh in, given that RAs have been known to deny codes based on provider documentation.
3. Be on the lookout for Coding Clinic advice clarifying this issue.  Coding Clinic for ICD-10-CM/PCS addressed some aspects of this in its fall 2016 publications for the third and fourth quarter. In addition to this advice, you may wish to submit your own cases to Coding Clinic advisors to see how they comment.

Editor’s note: This post is an excerpt from an article originally published in JustCoding. Click here to read the full version.