Tip: Maintain sepsis focus under RAC scrutiny
Septicemia has been problematic for some time. Coders often misunderstand the ICD-9-CM Official Guidelines for Coding and Reporting as it pertains to the sequencing of the assigned codes, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA.
“This is especially true with sepsis as it relates to septicemia and other underlying infections that can cause sepsis,” says McCall.
Many think the guidelines require septicemia to always be the principal diagnosis, when in fact that may not be the case depending on the documentation. The Guidelines read:
“Sepsis/SIRS with Localized Infection: If the reason for admission is both sepsis, severe sepsis, or SIRS and a localized infection, such as pneumonia or cellulitis, a code for the systemic infection (038.xx, 112.5, etc) should be assigned first, then code 995.91 or 995.92, followed by the code for the localized infection. If the patient is admitted with a localized infection, such as pneumonia, and sepsis/SIRS doesn’t develop until after admission see guideline 1.C1.b.2.b.(b) Sepsis and severe sepsis as secondary diagnoses: When sepsis or severe sepsis develops during the encounter (it was not present on admission), the systemic infection code and code 995.91 or 995.92 should be assigned as secondary diagnoses.”
This general confusion, McCall says, is one reason Connolly Healthcare, CMS’ recovery audit contractor (RAC) for Region C, included MS-DRG 871 (septicemia without mechanical ventilation 96+ hours with MCC) and MS-DRG 872 (septicemia without mechanical ventilation 96+ hours without MCC) in its list of 24 targeted DRGs to review.
The rules seem to imply that whenever a patient has sepsis and a localized infection—no matter what else occurred during an admission—that the principal diagnosis is automatically a code from the 038.xx series. This causes the case to group to MS-DRGs 870-872, she says.
CDI specialists need to keep a watchful eye on these and other common documentation and coding missteps.
ACDIS members can read more in the January 2010 issue of the CDI Journal in the article “Complex DRG audits reveal CDI target areas.”