SEPSIS
Definitions:
SIRS: Systemic inflammatory response syndrome (SIRS) is the body’s systemic response to infection, trauma, burns, pancreatitis, major surgery or other insult/injury.
Sepsis: SIRS due to an infection (either suspected or confirmed). SIRS due to other causes is not “sepsis,”
Clinical Criteria for SIRS/Sepsis¹:
If a patient can be described as “septic”, “toxic”, “ill-appearing” or other similar terminology, then two or more of the following indicate the presence of SIRS/sepsis:
- Fever (≥101˚F / 38.3˚C) or Hypothermia (<96.8˚F / 36.0˚C)
- Heart rate > 90
- Respiratory rate > 20
- WBC > 12,000 or <4,000 or Bands > 10%
Other clinical indicators also used by physicians to identify SIRS/sepsis include: altered mental status, hypotension, elevated C-reactive protein (CRP), elevated procalcitonin level, lactate level > 1, mottling of the skin, prolonged capillary refill, and non-diabetic hyperglycemia (>120). Finding some of these may be further clues that the patient has sepsis.
Because an authoritative definition of Sepsis did not exist prior to 1992 and the historical implications of the ominous prognosis associated with it, some physicians are reluctant to document the term “sepsis” even when the evidence-based clinical criteria are clearly met. In such circumstances, physicians may be much more comfortable documenting the currently equivalent terminology of “SIRS” due to [the underlying infection].”
¹Crit Care Med 2003;1250-1256
Treatment. May include IV antibiotics (often broad-spectrum, multiple), aggressive IV fluids to prevent organ failure, careful monitoring of vital signs and organ function, and often intensive care. Treatment with Xigris indicates severe sepsis.
Coding. Sepsis is coded with a minimum of two codes:
- Sequence first the systemic infection (038.0-038.9, 112.5, etc).
- Code also the appropriate SIRS code (995.91 or 995.92)
An additional code is also assigned for any localized infection(s) and associated manifestations of acute organ dysfunction if present. Therefore, if Sepsis (or the symptoms of Sepsis) is present on admission, the localized infection(s) and/or manifestations of severe Sepsis cannot be assigned as principal diagnosis. Codes 995.91 or 995.92 are never sequenced as principal diagnosis.
Severe Sepsis/SIRS, Official Coding Guidelines, Section 1.C.1.b state that: “Severe Sepsis {SIRS] generally refers to sepsis with associated acute organ dysfunction. If… the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than sepsis, do not assign code 995.92, severe sepsis. If the documentation is not clear…, query the provider.
The Tabular List enumerates several examples of acute organ dysfunction under code 995.92, using the words “such as” which means that the list is not all-inclusive. When these conditions represent a manifestation of severe sepsis, code 995.92 as well as the manifestations must be sequenced as secondary diagnoses.
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I-10: No significant changes. Unspecified sepsis (A41.9) and additional codes for severe sepsis (R65.2) or severe sepsis with septic shock (R65.21). No code assignment for “urosepsis”; provider must be queried.
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Clinical criteria for acute organ dysfunction that may be associated with severe sepsis include:
- Hypoxemia / Respiratory Failure
- Acute renal failure or oliguria (falling urine output)
- Septic hypotensive shock
- Encephalopathy / altered mental status
- Coagulopathy or DIC
(INR > 1.5, aPTT > 60, Platelets < 100,00)
- Hyperlactatemia (>4 mmo1/L)
- Liver failure (e.g., total bilirubin >4 mg/d1)
- Ileus (absent bowel sounds)
- Critical-illness myopathy
- Critical-illness polyneuropathy
Septic Shock (785.52): Refractory hypotension (BP <90/60) associated with sepsis lasting > one hour unresponsive to fluid challenge and usually requiring vasopressor therapy. It requires the use of code 995.92; do not assign 995.91 with 785.52.
Sepsis is a Complication: Sepsis is frequently due to the presence of a urinary catheter or vascular device, and, in such situations, should be coded to the appropriate complication codes (categories 996-999) which would be sequenced first.
Urosepsis: If only the non-specific term “urosepsis” is used, the physician should be queried to determine whether this is a simple UTI or sepsis due to the urinary tract infection. If only the term “urosepsis” is documented, then code 599.0 (urinary tract infection) is assigned.
Bacteremia: “Bacteremia” is defined as bacteria in the blood (i.e., positive blood culture). It does not constitute sepsis and, as a Chapter 16 code (790.7), should rarely be assigned.
Pediatric Sepsis/SIRS
Definition: Pediatric SIRS in the presence of, or as a result of, suspected or proven infection.
Infants and young children are often admitted as inpatients to “rule out sepsis”, meaning “bacterial sepsis”. These patients almost invariably meet pediatric SIRS criteria on admission; and SIRS is commonly caused by viral infections in infants and young children.
In such circumstances, pediatricians may document SIRS (when clinical criteria are met); and if cultures are all negative (i.e., bacterial sepsis is ruled out); viral infection would usually be the most likely cause. On the other hand, if a specific bacterial, viral, other infectious or non-infectious cause is identified, it should be specifically documented.
The clinical criteria for Pediatric Sepsis/Sirs are quite different from the adult criteria and also depend upon the age of the patient (5th & 95th percentiles as specified in the article* referenced below).
Clinical Criteria* (one must be Temperature or WBC):
- Core Temperature > 101.3˚F or <96.8˚F
- WBC elevated or depressed for age (not due to chemotherapy) or >10% bands
- Tachycardia (> 2 SD above nl for age not due to other stimuli), or
- Bradycardia (< 10th percentile for age not due to other specific causes), or
- Respiratory Rate (>2 SD above normal for age), or
- Mechanical Ventilation (not due to anesthesia or neuromuscular disease)
*Pediatri Crit Care Med 2005; 6(1):2-8