Health Information Management

Tip: Seven steps to sort out SIRS documentation

CDI Strategies, June 21, 2012

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Current SIRS criteria are insufficient, confusing, and don't indicate whether a patient is truly sick, says Robert S. Gold, MD, founder and CEO of DCBA, Inc., in Atlanta.

Some patients—particularly those who are critically ill—may meet necessary criteria for SIRS and truly have sepsis or another severe diagnosis. Others, however, may meet two of four criteria (e.g., heart rate > 90 and respiratory rate > 20)—which technically constitute a reportable diagnosis—but not have SIRS.
“Abnormalities in vital signs and abnormalities in laboratory studies can be due to things that are totally unrelated to a patient's infectious process in the body, or can be present totally unrelated to an inflammatory process in the body,” says Gold. “If there is no inflammatory process, docs should not call it SIRS because you must have an inflammatory process to get a systemic inflammatory response.”
For example, tachycardia with atrial fibrillation and rapid ventricular rate doesn't justify a SIRS diagnosis, says Gold. If a patient has leukocytosis with injection of steroids, this also doesn't imply SIRS. Similarly, tachypnea with tachycardia caused by running does not meet SIRS criteria, he says.
Review documentation thoroughly, query when necessary, and consider the following seven tips to ensure appropriate documentation and coding:
1. Note differences between streptococcal ­sepsis and streptococcal septicemia. Review clinical evidence in the record before querying physicians. Take caution when referencing SIRS criteria to avoid backing physicians into a corner to provide diagnoses that may technically satisfy diagnostic criteria without actually being present.
2. Look for linkage between organ dysfunction/failure and severe sepsis. Severe sepsis (995.92) occurs when sepsis is accompanied by signs of failure of at least one organ. Documentation of all organ dysfunctions and failures, including any related treatments (e.g., tracheostomy), is important with respect to supporting the overall diagnosis.
3. Know how to apply sequencing guidelines. If the patient is admitted to the hospital with a localized infection and then develops sepsis during their stay, the sequencing is clearer than if the patient appears to have been admitted for sepsis, organ failure, or something else. Review the Official Guidelines for Coding and Reporting and related AHA Coding Clinic for ICD-9-CM.
4. Wait for the discharge summary. If a physician documents a diagnosis as probable, suspected, likely, questionable, possible, or still to be ruled out at the time of discharge, coders can report the condition as if it existed or was established.
5. Note unique aspects of coding newborn ­sepsis. When a physician documents newborn sepsis, coders should report code 771.81 (septicemia [sepsis] of newborn) with a secondary code from category 041.x (bacterial infection in conditions classified elsewhere and of unspecified site) to identify the organism.
6. Encourage physicians to stop ­documenting ­urosepsis. This vague term currently maps to code 599.0 (UTI, site not specified) in ICD-9-CM. ­However, in ICD-10-CM, urosepsis is not a codeable term. The Alphabetic Index instructs coders to "code to the ­condition," and it doesn't provide a default code.
7. Don't make assumptions when coding post-procedural sepsis. "You cannot make an assumption that just because the patient has some type of post-procedure infection that develops into sepsis that the two [i.e., the procedure and sepsis] are related," says Avery. "Physicians must clearly document the cause-and-effect relationship."

Editor’s note: Gold spoke during ACDIS audio conference "Sepsis Coding: Learn Documentation Improvement Techniques to Ensure Accurate Coding."  This article excerpt was originally published in the June edition of Briefings on Coding Compliance Strategies.

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