Health Information Management

Q&A: Coding Clinic clarifies SIRS query questions

CDI Strategies, September 29, 2011

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Q:  How should I query for systemic inflammatory response syndrome (SIRS) if SIRS codes to sepsis? I want to correctly query and obtain the proper supporting information in the medical record in the event of an audit. Any discussion on this topic is appreciated.

A: This question raises two issues. First, SIRS does not code to sepsis. SIRS by itself codes to 995.90, Systemic inflammatory response syndrome, unspecified. SIRS codes to sepsis only when it is linked to an infection.
While the ICD-9-CM Official Guidelines for Coding and Reporting allow for pneumonia and urinary tract infection to be designated as infections (which, for pneumonia, is not always the case), other conditions that end with the suffix “-itis” that many assume to be infections, such as cellulitis, diverticulitis, orchitis, cholangitis, and the like, are not infections unless the physician explicitly states that these are infections.
SIRS due to any condition that is not explicitly documented to be an infection garners code 995.93 (a CC) or 995.94 (an MCC), depending on whether an acute organ dysfunction is linked to the SIRS. If it was the physician’s intention to state that SIRS was due to infection, the word “sepsis,” defined as SIRS due to infection, is preferred. The physician should use the term “SIRS” only if the intent is to communicate that the SIRS phenomenon is due to a noninfectious disease process.
The second issue addresses how to survive an audit. The definition of the term “SIRS” has evolved over the years. Some still hold to the 1992 definition where only two out of four SIRS criteria—primarily representing abnormal vital signs and/or a high or low white count—must be met. This definition and associated criteria are currently not in vogue, given that the inflammatory mediators in SIRS have myriad manifestations and consequences and that each indicator by itself is not specific for the disease.
Editor’s Note: James S. Kennedy, MD, CCS, managing director at FTI Healthcare in Brentwood, TN, and a member of the ACDIS advisory board, answered this question in the July edition of the CDI Journal.

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