![]() ![]() ![]() Guidance and direction published in the American Hospital Association ICD-10-CM/PCS Coding Clinic should also be adhered to. 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: There continues to be significant clinical research and work to standardize clinical terminology and clinical criteria, so we can expect more attention surrounding SIRS and Sepsis. As part of the Sepsis-3 publication, the Sequential Organ Related Assessment or SOFA and quick-SOFA or q-SOFA were introduced as a valuable tool to identify organ dysfunction and septic shock. They also stated that “severe sepsis” was a redundant term and definition so it was not further addressed. Clinically “Septic shock” would appear and be diagnosed when the patient has become hypotensive (i.e., less than 90 mmHg or a 40% drop in mmHg from previous normal blood pressure). In 2016, researchers and clinical experts published the consensus for a Sepsis -3 definition, stating: Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Their criteria were and are a little different from the ones above which may lead to confusion and documentation issues. Severe sepsis was felt to be Sepsis with organ dysfunction, but again, each patient is different, so providers need to make their own determination of whether a patient is septic or not.īy 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. temperature of 101☌ or higher) than the prior medical journals. ![]() The criterion that was published was more specific (i.e. Plasma procalcitonin (> 2 SD above the normal value)īeginning in 2003 the “Surviving Sepsis Campaign” started focusing on decreasing sepsis mortality and bringing more attention to the condition of sepsis. Plasma C-reative protein (> 2 SD above the normal value) Hyperglycemia (plasma glucose 120 mg/dL or 7.7 mmol/L) in the absence of diabetes Significant edema or positive fluid balance (20 mL/kg over 24 hours) In 2001 additional research consensus on Sepsis was published (called Sepsis 2) indicating that in addition to the 1991 criterion on SIRS, that there were other more specific clinical signs to consider when diagnosing SIRS included a change in mental status and several clinical/lab values that were not included in Sepsis 1: Tachypnea/Respiratory rate >20/min or PaCO2 12 000/mm3 or 10% immature bandsĪccording to this initial research study, if SIRS was present and there was an infection then a diagnosis of “Sepsis” could be made. A medical consensus on SIRS and Sepsis was published in 1991-1992 (Referred to as Sepsis 1), the SIRS criteria included two or more of the following (keep in mind that each patient is different so the signs/symptoms will vary): Over the years there have been many clinical experts, medical journals and medical societies publish information about SIRS and Sepsis. The golden rule for the HIM Coding and CDI professional is that we must have the diagnostic documentation by the provider in order to assign the ICD-10-CM code(s) and follow Official Guidelines.ĬLINICAL 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. 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). Post updated with 2020 guidelines on December 2019 by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10- CM/PCS Trainer. ![]()
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