Q&A: Septicemia versus bacteremia
Q: Our facility has adopted a systemwide definition of sepsis (based on Sepsis-3) and we’re having success with educating most providers. Some of our infectious disease providers, however, like to use the term septicemia which codes to A41.9, Sepsis, unspecified organism. This is somewhat of a conundrum when infectious disease providers use this term when the attending hospitalists are saying “no sepsis and/or just bacteremia” and the patient does not meet our systemwide sepsis definition.
Our physician advisors don’t think the infectious disease physicians should have to change their terminology since septicemia is different from sepsis and bacteremia. This puts both our CDI and coding teams in a difficult situation though since the documentation in the record from the infectious disease physician and the attending hospitalist is in conflict.
How can we appropriately code and/or query in this situation?
A: The first thing to point out is that we caused this problem. In ICD-9, CDI professionals trained our infectious disease and internal medicine doctors to preferentially use the word “septicemia.” In ICD-10-CM, though, “septicemia,” as you rightly point out, codes to sepsis unspecified.
As a physician advisor, I used to ask providers to raise their hand if they were bacteremic today, and then tease them about not brushing their teeth if they didn’t raise their hand. While this may seem like an inconsequential joke, this helped teach them the distinction between bacteremia and septicemia.
In reality, hospitals are rarely taking care of patients with asymptomatic bacteremia, and blood cultures are usually ordered for a reason.
When the Sepsis-3 definition was first introduced, one of the authors confirmed to me that bacteremia without acute organ dysfunction is not included in the definition of Sepsis-3. This caused your dilemma.
When you have a patient record listed with bacteremia, first go through the record with a fine-tooth comb looking for organ dysfunction and make sure it is not really a case of sepsis.
If not you’re left with a conundrum: You have a patient who is sick with localized infection with bacteremia and we are treating it with the same fervor as sepsis, but it is not considered sepsis.
If a patient is admitted because of bacteremia, it should be the principal diagnosis even though bacteremia is a symptom code, because it is the condition that occasioned the admission.
If, for example, a urinary tract infection patient were notified that their blood cultures were positive and told to go back to my ED, my documentation would read “bacteremia, rule out sepsis due to urinary tract infection.” If their blood tests were negative, they wouldn’t have been called to go back to the ED. In this instance, I would make it clear that I had serious concerns about bacteremia and was concerned the patient was at risk. I would need to justify medical necessity for the admission.
If bacteremia ends up being the principal diagnosis, it actually groups in the sepsis DRG set anyway. The issue is that the word “septicemia” seems to distinguish symptomatic bacteremia from brushing-teeth asymptomatic bacteremia; the term is a bit antiquated, like using severe sepsis which really isn’t a thing anymore either under the Sepsis-3 definition.
When I’m educating physicians, I use the following method:
- Documentation of the sepsis
- Documentation of localized infection
- Sepsis due to [infection]…
- Clinical support of the organ dysfunction
- Sepsis due to [infection] with acute sepsis-related organ dysfunction as evidenced by [specify organ dysfunctions]
This method accomplishes two things. First, it validates that there is sepsis-related life-threatening organ dysfunction. Secondly, it gives the coding professionals permission to use the R65.2, Severe sepsis, code without needing the physician to use the term “severe sepsis.”
With septicemia, it may be helpful to educate providers before sending a clinical validation query. You do need to resolve the conflicting documentation, but the physicians need to understand that septicemia without organ dysfunction is bacteremia; septicemia with organ dysfunction is sepsis.
Editor’s note: Erica E. Remer, MD, FACEP, CCDS, president of Erica Remer, MD, Inc., in Beachwood, Ohio, answered this question on an episode of the ACDIS Podcast.