Sepsis is a life-threatening organ dysfunction that results from the body’s response to infection. The information provided is for educational purposes only. E.g. By 2015, the Centers for Medicare and Medicaid (CMS) and the Joint Commission (TJC) developed a Core Measure Sep-1 to help identify sepsis and decrease mortality. ICD-10-CM OVERVIEW: When performing clinical coding and auditing, we must always follow the ICD-10-CM Official Guidelines for Coding and Reporting, which can be located at: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-Coding-Guidelines.pdf. CLINICAL OVERVIEW: Before we can discuss the ICD-10-CM coding of Systemic Inflammatory Response Syndrome (SIRS) and Sepsis, we need to have a clear understanding of the many clinical criteria that tell us SIRS is a precursor to Sepsis, which can lead to Severe Sepsis, that can then lead to Septic Shock. With the trend in management moving away from protocolized care in favor of … … Sepsis and septic shock: Guideline-based management, Evaluation and management of shock in patients with COVID-19, DOI: https://doi.org/10.3949/ccjm.87a.18143. In January 2020, the Global Burden of Disease team estimated that high income countries such as the UK would see between 200 and 270 cases of sepsis each year per 100,000 population - … The Surviving Sepsis Campaign: where have we been and where are we going? Briefly, the 3-hour bundle requires a lactate, blood cultures before antibiotics, antibiotics, and if a patient is unstable, large volume IV fluid administration (30 mL/kg). We know that SEPSIS is a life-threatening condition and there has been much discussed about this subject in many clinical circles as well as in clinical coding and clinical documentation improvement (CDI). Use of this website is subject to the website terms of use and privacy policy. Statement: Why IDSA did not endorse the Surviving Sepsis Campaign Guidelines. Version 1.4 . We anticipate the release of those recommendations in early 2020. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care, Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. However, CMS has stated that they have no plans to update their criteria in the near future. Cigna Medicare. 2020 Feb;21(2):e52-e106. Identifying patients with sepsis on the hospital wards, Prompting physicians to address a daily checklist and process of care and clinical outcomes: a single-site study, Quality improvement initiative for severe sepsis and septic shock reduces 90-day mortality: a 7.5-year observational study, Frequently asked questions about managing cancer pain: An update, Imaging to evaluate suspected infective endocarditis, Male and female pattern hair loss: Treatable and worth treating, Patient Subsets & Specific Organ Involvement, www.qualityforum.org/NQF_Revises_Sepsis_Measure.aspx, TOOLS FOR IDENTIFYING HIGH RISK: SOFA AND qSOFA, USUAL CARE VS PROTOCOLIZED INITIAL RESUSCITATION, Cleveland Clinic Center for Continuing Education. Furthermore, others o If multiple lactate levels are drawn within the specified time frame, use the highest lactate leveldrawn from the . The criterion that was published was more specific (i.e. Author: Krystal Baciak, MD (EM Resident Physician, Jacobi/Montefiore EM) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF) Since these 3 things occur within 6 hours of each other, the onset of sepsis time-zero defaults to the latest of these three things: lactic acid elevation at 15:45. It requires prompt recognition, appropriate antibiotics, careful hemodynamic support, and control of the source of infection. According to this initial research study, if SIRS was present and there was an infection then a diagnosis of “Sepsis” could be made. The code for the systemic infection should be assigned first, followed by a code for the localized infection (for example pneumonia); If the patient is admitted with a localized infection, and develops Sepsis after admission, a code for the localized infection is assigned first, followed by a code for the Sepsis or Severe sepsis; If the organism causing the Sepsis is documented, use a code in subcategory A41 (e.g., A41.51 Sepsis due to E. coli); Severe sepsis requires at least 2 ICD-10-CM codes; a code for the underlying systemic infection and a code from category R65.2 Severe Sepsis; you should also assign a code(s) for the acute organ dysfunction if documented; Codes R65.20 and R65.21 as not acceptable as Principal diagnosis and must be sequenced after a code for the underlying systemic infection; A code from ICD-10-CM code subcategory R65.2- (severe sepsis) would not be reported unless the physician has documented severe sepsis or an acute organ dysfunction; Currently, when there is documentation of Severe sepsis, there should be evidence of organ dysfunction or perfusion, Copyright © 2021 STAR Medical Auditing Services, LLC.