Work Through Sepsis and Other Infectious Diseases

Work Through Sepsis and Other Infectious Diseases Arlynn Hansell, PT, HCS-D, HCS-H, HCS-O, COS-C Owner Therapy and More, LLC Cincinnati, OH This is the Full Title of a Session 1

Learning Objectives At the completion of this educational activity, the learner will be able to: 1. Define the conditions related to infectious diseases. 2. Identify the difference between SIRS, sepsis, severe sepsis and septic shock, infectious versus non-infectious processes, and A and B organisms, and C Diff. 3. Common home health infections/complications related to GI/GU ostomies and catheters. 4. Discuss official coding guidelines associated with these conditions and documentation requirements. 2

Coding Concepts All coding is based on physician documentation. Code assignment issues related to inconsistent, missing, conflicting, or unclear documentation MUST be resolved by the physician. Do not code on the basis of laboratory or radiological findings alone, unless these reports have been signed or interpreted by a physician (e.g. pathologist/radiologist). 3

Required Documentation Often, sepsis and the acute infectious process are resolved in the inpatient setting. Consider whether sepsis remains unresolved at SOC. Do not assume this based on the continuation of oral antibiotics. The physician should be queried. Physician documentation should include: The inflammatory condition and if it is infectious or noninfectious; If infectious, the causal organism; and If noninfectious, what the specific underlying condition is. 4

Definitions (An Attempt at Clarity) 5

Infection Infection is defined as the invasion and multiplication of microorganisms such as bacteria, viruses, and parasites that are not normally present within the body. May be diagnosed based on clinical signs and symptoms, do not have to be confirmed by microbiology. Localized infection: affects only one body part or organ. E.g. Bladder infection, cellulitis Systemic infection: infection in the bloodstream. E.g. Sepsis, septicemia, blood infection, blood poisoning, bacteremia, flu, strep throat, common cold 6

Localized Infection: is an infection that is limited to a specific part of the body and has local symptoms, such as cellulitis, pneumonia, or a UTI. Pneumonia Cellulitis of the arm UTI Source: http://bodypictures.org/large/98/inside-the-human-body-pictures-1.jpg 7

Bacteremia and Bacteriuria Bacteremia (R78.81) is the presence of bacteria in the blood, and Bacteriuria (R82.71) is the presence of bacteria in the urine, both identified through laboratory testing. They are most often asymptomatic; and They can progress to a systemic inflammatory response (SIRS) or to a systemic infection (Sepsis). Documentation of bacteremia or bacteriuria with clinical signs and symptoms of a systemic infection such as fever, chills, or tachycardia should be clarified with the physician to ensure proper code assignment. 8

Source: https://en.wikipedia.org/wiki/sepsis#/media/file:sepsis_steps.png 9

SIRS 10

SIRS Systemic inflammatory response syndrome (SIRS) is an inflammatory state affecting the whole body, frequently a response of the immune system to infection. It may also be a response to a non-infectious condition, such as: trauma, burns, cancer, immunodeficiency, MI, complications of surgery, hemorrhage, adrenal insufficiency, pulmonary embolism, ischemia, acute pancreatitis, and drug overdose. Symptoms include elevated or reduced temperature, rapid heart rate (tachycardia), rapid respirations (tachypnea), and elevated white blood count (leukocytosis). 11

Urosepsis Urosepsis is a systemic reaction of the body (SIRS) to a bacterial infection of the urogenital organs. Per chapter-specific coding guidelines (Ch.1) for sepsis: The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Urosepsis - code to condition Should a provider use this term, he/she must be queried for clarification. Is this a UTI, bladder infection, or bloodstream-specific infection? 12

Sepsis 13

Sepsis Sepsis is a life-threatening condition that arises when the body s response to an infection injures its own tissues and organs. JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287 Sepsis is most commonly caused by a bacterial infection, but it may be caused by virus, fungi and/or parasites. Viral Sepsis is a systemic infection caused by the presence of a virus in the blood. Septicemia and sepsis are often used synonymously use caution. Resolving sepsis, per Coding Clinic Q1 2018, is not considered actively septic, so only code the underlying infection that triggered the sepsis. 14

Sepsis Alpha Index: Septicemia A41.9 meaning sepsis see Sepsis The codes assigned depend on: The underlying cause of the sepsis; The causative organism; and Other co-existing problems. 15

Sepsis Syndrome When the term sepsis syndrome is documented, more information must be obtained. Guidance from the Coding Clinic, 2nd quarter 2012, states, The term sepsis syndrome is poorly defined. Query the physician to determine the specific condition(s) the patient has. 16

Severe Sepsis 17

Severe Sepsis Severe sepsis is when the infection is severe enough to affect the function of the patient s organs, such as: Acute respiratory failure (J96.0-) Acute kidney failure (N17.-) Acute hepatic failure (K72.0-) or Multiple organ dysfunction (MOD) Note: If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that a medical condition, other than sepsis, is the cause of the organ dysfunction, do not assign a code from R65.2-, Severe sepsis. Severe sepsis may progress to septic shock. 18

Septic Shock 19

Septic Shock Septic shock (a subset of sepsis) is when the patient experiences circulatory failure: a significant drop in blood pressure with cellular metabolism abnormalities due to sepsis (reminder, sepsis is organ damage in response to infection). It can lead to respiratory or heart failure, stroke, organ failure, or death. Septic shock indicates the presence of severe sepsis. Most common organs to experience damage: lungs, brain, urinary tract, skin, or abdominal organs. Frequently cared for in the ICU (25-40% mortality rate). 20

Infectious Diseases 21

Chapter 1: Infectious and Parasitic Diseases (A00-B99) Infectious refers to a disease caused by a micro-organism or capable of being communicated by infection (contagious). Parasitic refers to a disease caused by a parasite (e.g., a tick). Code selection is usually determined by the specific organism involved in the disease process. 22

Chapter-Specific Guidelines This section includes coding guidelines for: Human Immunodeficiency Virus (HIV) Infections; Infectious agents as the cause of diseases classified to other chapters; Infections resistant to antibiotics; Sepsis, Severe Sepsis, and Septic Shock; Methicillin Resistant Staphylococcus aureus (MRSA) Conditions 23

Infectious Agents Certain infections are classified in chapters other than Chapter 1 with a Use Additional Code convention. In these instances, it is necessary to use an additional code from Chapter 1 to identify the organism, if known, as the cause of diseases classified to other chapters B95: Streptococcus, Staphylococcus, and Enterococcus B96: Other bacterial agents, such as Klebsiella pneumoniae, E. coli, and Pseudomonas B97: Viral agents, such as Adenovirus, Enterovirus, and Corona virus 24

Sequencing of B Codes B95, B96, and B97 are sequenced after what is infected. Code the underlying disease process first. These categories are to be used as supplementary or additional codes to identify the infectious agent(s) in diseases classified elsewhere. For example: Acute infective endocarditis due to Staph aureus I33.0 Acute and subacute infective endocarditis B95.61 Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere (MSSA; Staph aureus NOS) 25

Staphylococcus Staphylococcus ( Staph ) is a species of gram-positive bacteria. There are over 40 types of staph, but Staphylococcus aureus causes most staph infections, including: Skin infections Pneumonia Food poisoning Toxic shock syndrome Blood poisoning (bacteremia) 26

Staphylococcus (cont.) Staphylococci are the most abundant skin-colonizing bacteria and the most important causes of nosocomial infections and community-acquired skin infections. Skin colonization refers to bacteria that lives on the skin. Nosocomial infection, also known as Hospital-acquired infection (HAI), is an infection that is contracted from the environment or staff of a healthcare facility. Community-acquired infection (CAI) is an infection acquired in the community. 27

Colonization Everyone is "colonized" with bacteria that live on the skin or in the body nose, mouth, and digestive tract which do not cause any medical problems. In fact, these harmless bacteria help prevent over-growth of dangerous bacteria. Colonization or carriage means that the bacteria is present on or in the body without necessarily causing illness. If it is documented that a patient has MSSA or MRSA colonization and infection, both codes may be assigned. 28

Carrier A person who has a positive MSSA or MRSA colonization test, which may be stated as screen positive or swab positive, is known as a carrier. A carrier does not necessarily have an active infection, but may have a positive swab in the nose, axilla, etc., and is coded as: Z22.321 Carrier or suspected carrier of MSSA Z22.322 Carrier or suspected carrier of MRSA 29

Streptococcus The Streptococcus ( Strep ) organism is a spherical grampositive bacteria which can cause infections that vary in severity from a mild sore throat to pneumonia. Most Strep bacteria respond well to antibiotic therapy, if the illness is identified and treated early. There are more than 20 different types of strep bacteria, which are mainly classified into two groups: Group A Group B 30

Group A & B Streptococcus Group A streptococci (GAS) are bacteria commonly found in the nose, throat and on the skin, which are usually spread by direct human transfer. Serious, sometimes life-threatening, group A strep disease may occur when bacteria gets into parts of the body where bacteria usually are not found, such as the blood, muscle, or the lungs. These infections are termed "invasive group A strep disease. Group B Streptococcus (GBS) is a type of bacteria often found in the intestines or lower genital tract. Usually harmless in healthy adults, Group B strep can cause dangerous infections in people with certain chronic medical conditions, such as diabetes, heart failure, cancer, or liver disease. 31

Resistance to Antibiotics Per the CDC, each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant. Assign a code from category Z16, Resistance to antimicrobial drugs, after the organism, only if the code does not identify drug resistance. For example: Enterocolitis due to Clostridium difficile resistant to Flagyl A04.7-, Enterocolitis due to Clostridium difficile Z16.39, Resistance to other specified antimicrobial drug 32

C. Diff: Enterocolitis Due to Clostridium Difficile C. diff causes enteric (intestinal) disease by producing toxins: Mild to severe diarrhea Pseudomembranous colitis (a life-threatening inflammation of colon) Infection is most commonly associated with a history of antibiotic use and admission to an inpatient facility Affects more than 500,000 patients annually Recurrence rate of 45% Highly resistant to most antibiotics but can be treated by vancomycin, IV infusion, or fecal transplant 33

MSSA Methicillin Susceptible Staphylococcus Aureus, B95.61, is used when the bacteria is identified as Staph aureus or MSSA. MSSA usually causes skin infections, but can also cause pneumonia and other serious types of infections. Related skin infections most frequently present as pimples, boils, abscesses, or infected cuts. 34

MRSA MRSA (Methicillin Resistant Staphylococcus Aureus) cause a variety of illnesses in different parts of the body skin, surgical wounds, bloodstream, lungs, and urinary tract. MRSA is more difficult to treat than most strains of Staph aureus, due to its resistance to some commonly used antibiotics, which include: Penicillins (methicillin, dicloxacillin, nafcillin, oxacillin, etc.) Cephalosporins. Therefore, it is sometimes called a super bug. 35

HIV Disease (B20) Acquired Immune Deficiency Syndrome [AIDS] AIDS-related complex [ARC] HIV infection, symptomatic Use additional code(s) to identify all manifestations of the HIV infection. Code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline Section II.H, which states if the documentation indicates uncertainty e.g., possible, probable, or likely code the condition as if it existed or was established. Confirmation does not require a positive serology or culture for HIV. The physician s statement that the patient is HIV positive or has an HIV-related illness is sufficient. 36

Asymptomatic HIV Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be assigned when the patient has no documentation of symptoms, but documentation states, HIV positive, known HIV, HIV test positive, or similar terminology. Do not use this code: If the term AIDS is used; or If the patient is treated for any HIV-related illness; or If the patient is described as having any condition(s) resulting from his/her HIV status. Code B20 (HIV disease) instead. 37

Previously Diagnosed HIV Patients with any known prior diagnosis of HIV-related illness (opportunistic infection) should be coded to B20. Once diagnosed, B20 should always be assigned on every subsequent admission/encounter. Patients previously diagnosed with any HIV illness (B20) should never be assigned to: R75 Inconclusive laboratory evidence of HIV Z21 Asymptomatic HIV infection status Note: There is no code for history of HIV disease, since there is no cure, and it is always an active condition. 38

Use B20 with CAUTION! Some states and U.S. territories will deny B20 (HIV) as the primary diagnosis, under privacy protection laws, and some prohibit coding it at all. In these cases, look for an HIV-related condition, such as Pneumocystosis, B59, and sequence this as the first-listed diagnosis, with B20 as a secondary code. 39

States with Restrictions Alaska Arizona California Colorado Connecticut DC Delaware Hawaii Idaho Illinois Nevada New Jersey New Mexico North Dakota Oregon Puerto Rico South Carolina Texas Utah Washington West Virginia Wisconsin Wyoming These states restrict the coding of B20 as primary, some prohibit the use of the code altogether. Contact the state OEC for specific restrictions. 40

Infections Not Located in Chapter 1 Certain infections are classified in chapters other than Ch. 1, and no organism is identified as part of the infection code e.g., cellulitis, cystitis, ostomy, and UTI. In these instances, it is necessary to use an additional code to identify the organism. A code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, is to be used as an additional code to identify the organism. An instructional note will be found at the infection code noting to use an additional code for the organism. Doing this only pertains to when the organism is known. 41

Artificial Openings of the Digestive System (Chapter 11) All colostomy (cecostomy), gastrostomy, enterostomy (ileostomy; jejunostomy), and esophagostomy complications are coded to category K94. K94 codes include infection, hemorrhage, mechanical complications, such as excoriation and denuding of the skin surrounding the ostomy, and other complications. For an infection of the ostomy site, an additional code should be used to identify the infection, such as cellulitis or sepsis. Also the organism, if known. When there is an ostomy complication, do not assign a Z code for the ostomy, since Z codes indicate routine care. 42

Artificial Openings of the Urinary Tract (Chapter 14) All cystostomy and other urinary stoma complications (including ileal conduit, urostomy, and nephrostomy) are coded to N99.51-N99.53. There is no listing in the Index for ileal conduit and urostomy. See Complications, stoma, urinary tract. Ileal conduit (ileoconduit): system of urinary drainage which a surgeon creates using the small intestine after removing the bladder. A short segment of the small intestine is placed at an opening made on the surface of the abdomen to create a stoma. The ureters, which normally carry urine from the kidneys to the bladder, are then attached to the other end of the segment of intestine. The urine now travels from the kidneys, via the ureters and the newly formed ileal conduit, to the stoma and out into a collecting pouch known as an ostomy bag (or urostomy.) This is worn outside the body around the stoma 24 hours a day. This type is a form of incontinent urostomy. It is NOT a colostomy or ileostomy (bowel diversion). Source: https://www.bcan.org/assets/ileal-q-a-.pdf 43

Continent vs. Incontinent There are two types of urinary diversion: 1. Continent Requires that a tube be inserted into the stoma to the internal pouch to drain the urine 4 or 5 times a day. 2. Incontinent Opening in abdomen that drains urine continuously into an external ostomy bag (ileal conduit). Most common type seen in home health. 44

Coding Guidance 45

Coding Tools Finding the Codes Manual Electronic 46

Think BASICS Start In the Alphabetic Index! Look up the condition (e.g. pneumonia): Find the subentry in (due to) to locate the organism or other cause A subterm for the organism always takes precedence over a more general subterm (e.g. acute, chronic) when both subterms occur at the same indention level. For example, for chronic cystitis due to gonococcus: Cystitis Chronic Gonococcal this would be coded, as the organism takes precedence over chronic Look up the organism: May have its own entry, such as Staphylococcus, staphylococcal May be listed under Infection or Sepsis Then find the condition indented under the main term. If not found under the condition, such as cystostomy infection, look under Complication(s). Next, verify the code in the Tabular List. 47

Coding: Sepsis Coding sepsis does not require proof of a positive culture. Assign the code for the underlying systemic infection first: A40.- Streptococcal sepsis; or A41.- Other sepsis A40 and A41 categories are combination codes that describe both the systemic inflammatory response (SIRS) and the organism causing it e.g., A41.52, Sepsis due to Pseudomonas. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism. 48

Coding: Sepsis With Localized Infection If the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis: 1. Code the underlying systemic infection first 2. Then code the localized infection 49

Coding: Severe Sepsis and Septic Shock Coding guidelines instruct to assign: 1. Code for the underlying systemic infection; 2. Code from subcategory R65.2-, Severe sepsis; R65.20 Severe sepsis without septic shock; or R65.21 Severe sepsis with septic shock 3. Additional code(s) for any associated acute organ dysfunction Exception: If circulatory failure is the only dysfunction, that is not coded, as septic shock indicates the presence of circulatory failure. Note: The codes for severe sepsis and septic shock (R65.2-) can never be listed as primary. 50

Coding: Postprocedural Sepsis Sepsis resulting from a postprocedural infection is a complication of care. The physician MUST clearly document or confirm the causeand-effect relationship. 1. Code first the postprocedural infection code (e.g. T80.2-, Infections following infusion, transfusion, and therapeutic injection; T81.4-, Infection following a procedure; T88.0-, Infection following immunization; or O86.0-, Infection of obstetric surgical wound. 2. Next code the specific infection (A40.- or A41.-). In cases of severe sepsis, assign R65.20 (Severe sepsis without shock) and additional code(s) for any acute organ dysfunction. (See slide 50). 51

Coding: Postprocedural Septic Shock If a postprocedural infection has resulted in postprocedural septic shock: 1. Code first the precipitating complication (e.g. T81.4-, Infection following a procedure, or O86.0-, Infection of obstetrical surgical wound) 2. Next code T81.12-, Postprocedural septic shock; 3. Next, assign a code from category A40 or A41 for the systemic infection 4. Then assign code(s) for any associated acute organ dysfunction as applicable. 52

Coding: SIRS Due to Non-Infectious Process When SIRS is documented as due to a noninfectious disease process, and there is no subsequent infection: 1. Code first the underlying condition, such as an injury. 2. Next code: R65.10, Systemic inflammatory response syndrome (SIRS) of noninfectious origin without acute organ dysfunction or R65.11, Systemic inflammatory response syndrome (SIRS) of noninfectious origin with acute organ dysfunction. 3. If acute organ dysfunction is documented, use additional code(s) to specify the dysfunction e.g., hepatic failure. 53

Coding: Sepsis/Severe Sepsis Associated With Noninfectious Process If sepsis or severe sepsis is documented as associated with a noninfectious condition, e.g. burn or serious injury, and this condition meets the definition for principal diagnosis. 1. Code the noninfectious condition 2. Then code the resulting infection (systemic) If severe sepsis is present, a code from subcategory R65.2, Severe sepsis, should also be assigned. Followed by the associated organ dysfunction(s) codes 54

Coding: Sepsis/Severe Sepsis Associated With Noninfectious Process (cont.) If the infection meets the definition of principal diagnosis, it should be sequenced before the noninfectious condition. When both the associated noninfectious condition and the infection meet the definition of principal diagnosis, either may be assigned as the principal diagnosis. Only one code from category R65 should be assigned. Therefore, a code from subcategory R65.1, SIRS of noninfectious origin, should not also be assigned. 55

Coding: Viral Sepsis Per Q3 2016 Coding Clinic guidance: First, A41.89 (Other specified sepsis) is the code to assign for a diagnosis of viral sepsis. While the code is non-specific and falls into a category that covers bacterial illnesses, it is the best available option as ICD-10 does not currently provide a specific code for viral sepsis. Then, if the specific viral agent is not documented, add an additional code, B97.89 (Other viral agents as the cause of diseases classified elsewhere) to convey the information that the infection is viral in nature. Assign a third code from category R65.2- (Severe sepsis) only if the viral sepsis is documented as severe or if associated acute organ dysfunction is documented. Base the assignment of sepsis codes only on the physician s diagnosis and documentation, and never on clinical definitions or criteria or on clinical signs alone. 56

Coding: C. Diff Subcategory A04.7 yielded two codes in 2018: A04.71, Enterocolitis due to Clostridium difficile, recurrent A04.72, Enterocolitis due to Clostridium difficile, not specified as recurrent Important to get this distinction correct, as more resources may be needed for the recurrent type. 57

Coding: UTI Looking up urinary tract infection in the Alpha Index Tabular yields: + N39.0 Urinary tract infection, site not specified Has a Use additional code (B95-B97) convention to identify infectious agent. Urinary tract includes: Kidneys: N15.9 Ureters: N28.86 Bladder: N30 Urethra: N34 Use Z87.440 Personal history of urinary (tract) infections: UTI is resolved Patient has recurrent infections Bacteriuria (ref. slide 8) is not coded as a UTI. 58

Coding: MRSA A Combination Code B95.62, MRSA infection as the cause of diseases classified elsewhere, is a combination code. Includes the organism and Resistance to penicillins Do not assign a code from subcategory Z16.11, Resistance to penicillins, as an additional diagnosis. BUT: If MRSA is documented as resistant to another antibiotic, e.g. Vancomycin: Add a Z16 code for the other antibiotic. 59

Coding: MRSA There are two disease processes that include all 3 elements in the combination code for MRSA infection, causative organism, and resistance to penicillins and only one code is required: J15.212, Pneumonia due to MRSA A41.02, Sepsis due to MRSA If the documentation indicates MRSA as the cause of any other infection, two codes are required. For example: Cellulitis of left leg due to MRSA L03.116, Cellulitis of left lower limb B95.62, MRSA as the cause of diseases classified elsewhere Cellulitis Lymphangitis Source: https://en.wikipedia.org/wiki/cellulitis 60

History of MRSA If a patient had MRSA that no longer exists and is not receiving any treatment, but has the potential for recurrence and may require continued monitoring or may impact the plan of care, assign the history code. Z86.14, Personal history of MRSA infection For example, a patient with a sutured laceration of his right forearm, which became infected with MRSA, completed a course of IV and oral antibiotics, but requires continued wound care. S51.811D, Laceration without foreign body of right forearm Z86.14, Personal history of MRSA infection 61

Let s Walk Through These Scenarios Bacteremia, E. coli Postprocedural sepsis Tracheostomy, cellulitis, Strep A SIRS, pancreatitis Postprocedural septic shock Gastrostomy, staph infection Sepsis HIV UTI, Foley, E. coli Streptococcal sepsis, cellulitis Severe sepsis, septic shock MRSA sepsis, septic shock Cellulitis, Staph Aureus, colostomy 62

Bacteremia, E. Coli Bacteremia due to a bladder infection caused by E. coli. Cystitis, unspecified without hematuria N30.90 Unspecified Escherichia coli (E. coli) as the cause of disease classified elsewhere B96.20 Bacteremia R78.81 Rationale: Category N30 instructs to Use additional code to identify infectious agent (B95-B97). Additional codes B95-B97 are used to identify the bacterial agent causing an infection and are sequenced after the infection. R78.81 is a symptom code. Follow the chapter-specific guidance to report a symptom code as an additional diagnosis when it describes a significant aspect of the condition but is not an integral part of it. 63

SIRS SIRS due to acute pancreatitis Acute pancreatitis, unspecified K85.9 Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction R65.10 Rationale (ref. slide 53): The non-infectious process causing SIRS is coded first. Since there is no mention of an infection or organ dysfunction, SIRS (R65.10) is listed next. 64

Sepsis Third degree burn of chest wall resulting in sepsis being treated with IV antibiotics for 6 wks. Sepsis, unspecified organism A41.9 Burn of third degree of chest wall Add Z45.2, Z79.2 as well for the IV, antibiotics T21.31XA Rationale (ref. slide 48): The systemic infection (sepsis) is coded first. Since the organism is not specified, A41.9 is assigned. The injury causing the sepsis is coded next. A (initial encounter) is the appropriate 7 th character, since the patient is on antibiotics, which is considered active treatment. 65

Streptococcal Sepsis, Cellulitis, Wound Patient with streptococcal sepsis and cellulitis of the left lower leg due to a dog bite is admitted for IV antibiotics. Streptococcal sepsis, unspecified A40.9 Open bite, left lower leg S81.852A Cellulitis of left lower limb L03.116 Fitting and adjustment of vascular catheter Z45.2 Long-term (current) use of antibiotics Z79.2 Rationale (ref. slide 48): The systemic infection (sepsis) is sequenced first; Followed by the underlying cause (trauma wound). If cellulitis is associated with a wound, code the wound first. 7 th character A is assigned, since the patient is receiving antibiotics. 66

Severe Sepsis and Septic Shock MSSA pneumonia resulting in sepsis and respiratory failure. Sepsis due to MSSA A41.01 Severe sepsis without septic shock R65.20 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia Same patient: Severe sepsis progresses to septic shock. J96.90 Pneumonia due to MSSA J15.211 Sepsis due to MSSA A41.01 Severe sepsis with septic shock R65.21 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia J96.90 Pneumonia due to MSSA J15.211 67

Let s Look at the Rationale (ref. slide 49): The systemic infection is sequenced first. The presence of an acute organ dysfunction (respiratory failure) due to sepsis indicates severe sepsis. Therefore, severe sepsis is listed next: R65.20, without septic shock or R65.21, with septic shock followed by the organ dysfunction(s). (Respiratory failure) Then, the localized infection is coded. The combination code for pneumonia and the organism (MSSA) is assigned. 68

Postprocedural Sepsis Dehisced sternal incision post CABG resulting in sepsis due to Pseudomonas being treated with a wound vac. Disruption of external operation (surgical) wound, not elsewhere classified T81.31XA Sepsis due to Pseudomonas A41.52 Rationale (ref. slide 51): The postprocedural complication (dehiscence) is sequenced first. Treatment with a wound vac is considered active care. Therefore, the appropriate 7th character is A. The systemic infection code is listed next. 69

Postprocedural Sepsis Patient became septic due to E. coli urinary tract infection following an appendectomy. Infection following a procedure T81.4XXA Sepsis due to E. coli A41.51 UTI, site not specified N39.0 CY 2019 code addition: T81.44X-, Sepsis following a procedure Rationale (ref. slide 51): 1. The postprocedural complication (infection) is sequenced first. 2. Infection code(s) Do not assign B96.20 (Unspec E. coli) because A41.51 already identifies the causal bacterium for both the sepsis and the UTI. 70

Postprocedural Septic Shock Gram-negative sepsis resulting in septic shock and acute kidney failure due to an infected new colostomy being treated with antibiotics and intravenous fluids Colostomy infection K94.02 Postprocedural septic shock T81.12xA Gram-negative sepsis, unspecified A41.50 Acute kidney failure, unspecified N17.9 Rationale (ref. slide 52): Code first the underlying infection; Followed by code T81.12-, Postprocedural septic shock. Codes for the systemic infection and any associated acute organ dysfunction should also be assigned. 71

HIV If the patient is admitted for a HIV-related condition, report B20, HIV disease, as the principal diagnosis (when permitted by state law) followed by diagnosis codes for all reported HIVrelated conditions. Human immunodeficiency virus [HIV] disease B20 Pulmonary histoplasmosis capsulati, unspecified B39.2 If the patient is admitted for an unrelated condition, code that condition first, followed by B20 and additional related conditions. Unspecified fracture of upper end of right radius Human immunodeficiency virus [HIV] disease S52.101D B20 Candidal stomatitis (Oral thrush) B37.0 72

MRSA Sepsis, Septic Shock MRSA sepsis following a crushing injury of right lower leg with sepsis being the focus of care. Sepsis due to MRSA A41.02 Crushing injury of right lower leg S87.81XA Same patient develops septic shock, which is the focus of care. Sepsis due to MRSA A41.02 Crushing injury of right lower leg S87.81XA Severe sepsis with septic shock R65.21 73

Let s Look at the Rationale (ref. slides 49, 59) The infection (sepsis) meets the definition of principal diagnosis, since it is the focus of care. Therefore, it should be sequenced before the noninfectious condition (injury). Sepsis is identified with the appropriate systemic infection code (A40- or A41-). Severe sepsis/septic shock requires an additional code R65.2-, Sepsis without or with septic shock. Septic shock includes circulatory failure. Since no other acute organ dysfunction is noted, it is not necessary to assign an additional code. 74

Colostomy, Cellulitis, Staph Aureus Patient is admitted with cellulitis surrounding his colostomy, which is noted as due to Staph aureus. Colostomy infection K94.02 Cellulitis of abdominal wall L03.311 Methicillin susceptible Staph aureus infection as the cause of diseases classified elsewhere B95.61 Note: There is no instructional note at the ostomy infection codes to use an additional code to identify the organism, but there is for all categories L00-L08 (Infections of the skin and subcutaneous tissue). 75

Tracheostomy Cellulitis, Strep A A tracheostomy infection with cellulitis due to Strep A. Infection of tracheostomy stoma J95.02 Cellulitis of neck L03.221 Streptococcus, group A, as the cause of diseases classified elsewhere B95.0 Rationale (ref. slide 42): For an infection of the ostomy site: J95.02 has a Use additional code convention to identify the infection (e.g. cellulitis or sepsis). L03.- has a coding tip to code the ostomy complication first. Code the organism, if known. When there is an ostomy complication, do not assign a Z code for the ostomy, since Z codes indicate routine care. 76

Gastrostomy, Staph A gastrostomy infected with Staph. Gastrostomy infection K94.22 Unspecified staphylococcus as the cause of diseases classified elsewhere B95.8 Rationale (ref. slide 42): K94.22 has a Use additional code convention to identify the infection (e.g. cellulitis or sepsis). B95.- has a coding tip to code the ostomy complication (type of infection) first. Code the organism, if known. When there is an ostomy complication, do not assign a Z code for the ostomy, since Z codes indicate routine care. 77

UTI, E. Coli, Foley Catheter A urinary tract infection documented by the MD as due to E. coli and the Foley catheter. Infection due to indwelling urinary catheter Rationale: T83.5- has a Use additional code convention to identify the infection (UTI in this example). N39.0 has a Use additional code (B95-B97) convention to identify the infectious agent (E. coli in this example) B96.- has a coding tip to code the type of infection first. T83.511A Urinary tract infection, site not specified N39.0 Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere B96.20 When there is an ostomy/device complication, do not assign a Z code for the ostomy/device, since Z codes indicate routine care. 78

Bladder Infection, Candidiasis A bladder infection due to Candidiasis. Candidal cystitis and urethritis B37.41 Look up Bladder Infection says to see Cystitis nothing looks good, default is N30.90. Look up N30.90 (Cystitis, unspecified). At N30, there is a Use additional code to identify infectious agent (B95-B97) SO: look up Candidiasis, look down the indents to Cystitis B37.41 Tabular, B37.41: Coding tips state it is a combination code which includes the infection and organism. Do not assign a code for urinary infection (good ole UTI N39.0). 79

Resources Hard to Find Codes, Situations 80

Common Bacteria Gram-Negative E. Coli Enterobacter Klebsiella Proteus Pseudomonas Salmonella Shigella Gram-Positive Lactobacillus Listeria Mycobacterium Staphylococcus Streptococcus 81

Complications of Bariatric Procedures Condition K95.0 Complications of gastric band procedures Instruction K95.01 Infection due to gastric band procedure K95.09 Other complications of gastric band procedure K95.8 Complications of other bariatric procedure K95.81 Infection due to other bariatric procedure K95.89 Other complications of other bariatric procedure Instructional note at K95.01 and K95.81 to use additional code to specify type of infection or organism, such as: bacterial and viral infectious agents (B95.-, B95.6-) cellulitis of abdominal wall (L03.311) sepsis (A40.-, A41.-) 82

Condition Sepsis secondary to viral syndrome; viral syndrome is not further specified. Instruction Code A41.89 (Other specified sepsis) for the viral sepsis followed by B34.9 (Viral infection, unspecified) for the viral syndrome. Viral sepsis secondary to acute rhinovirus bronchitis Viral sepsis due to acute viral bronchitis due to influenza A Code A41.89 (Other specified sepsis) for the viral sepsis followed by J20.6 (Acute bronchitis due to rhinovirus) for the acute rhinovirus bronchitis Code A41.89 (Other specified sepsis) for the viral sepsis followed by J10.1 (Influenza due to other identified influenza virus with other respiratory manifestations) for the influenza A and J20.8 (Acute bronchitis due to other specified organisms) for the acute viral bronchitis. Note: A code from J09.X- (Influenza due to identified novel influenza A virus) is not appropriate in this scenario because these codes capture novel influenza A, not ordinary seasonal influenza A. 83

Condition Sepsis secondary to influenza B Sepsis from influenza with pneumonia Viral sepsis secondary to acute hepatitis B infection Sepsis due to Lyme disease Sepsis due to West Nile virus, and West Nile encephalitis Instruction Code A41.89 (Other specified sepsis) for the viral sepsis followed by J10.1 (Influenza due to other identified influenza virus with other respiratory manifestations) for the influenza B. Code A41.89 (Other specified sepsis) for the viral sepsis followed by J11.00 (Influenza due to unidentified influenza virus with unspecified type of pneumonia) for the influenza with pneumonia. Code A41.89 (Other specified sepsis) for the viral sepsis followed by B16.9 (Acute hepatitis B without delta agent and without hepatic coma) for the acute hepatitis B infection. Code A41.89 (Other specified sepsis) for the sepsis followed by A69.29 (Other conditions associated with Lyme disease) for the Lyme disease. Code A41.89 (Other specified sepsis) for the viral sepsis followed by A92.31 (West Nile virus infection with encephalitis) for the West Nile virus and West Nile encephalitis. 84

Condition Sepsis due to Dengue fever Instruction Code A41.89 (Other specified sepsis) for the viral sepsis followed by A90 (Dengue fever [classical dengue]) for the Dengue fever Sepsis due to acute viral gastroenteritis Code A41.89 (Other specified sepsis) for the viral sepsis followed by A08.4 (Viral intestinal infection, unspecified) for the acute viral gastroenteritis. Acute respiratory failure due to severe viral sepsis Code A41.89 (Other specified sepsis) for the viral sepsis, followed by B97.89 (Other viral agents as the cause of diseases classified elsewhere) for the unspecified viral agent, then R65.20 (Severe sepsis without septic shock) for the severe sepsis and finally J96.00 (Acute respiratory failure, unspecified whether with hypoxia or hypercapnia) for the acute respiratory failure 85

2019 Changes 86

Coding: Postprocedural Sepsis (Compare to slide 51 for 2018 coding) Sepsis resulting from a postprocedural infection is a complication of care. The physician MUST clearly document or confirm the causeand-effect relationship. 1. Code first the postprocedural infection code (e.g. T80.2-, Infections following infusion, transfusion, and therapeutic injection; T81.40 T81.43, Infection following a procedure; T88.0-, Infection following immunization; or O86.0-, Infection of obstetric surgical wound. 2. Assign an additional code for sepsis following a procedure (T81.44) 3. Next code the specific infection (A40.- or A41.-). In cases of severe sepsis, assign R65.20 (Severe sepsis without shock) and additional code(s) for any acute organ dysfunction. (See slide 50). 87

Coding: Postprocedural Septic Shock (Compare to slide 52 for 2018 coding) If a postprocedural infection has resulted in postprocedural septic shock: 1. Code first the precipitating complication (e.g. T81.40 to T81.43, Infection following a procedure, or O86.0-, Infection of obstetrical surgical wound) 2. Assign an additional code for sepsis following a procedure (T81.44) 3. Next code T81.12-, Postprocedural septic shock; 4. Next, assign a code from category A40 or A41 for the systemic infection 5. Then assign code(s) for any associated acute organ dysfunction as applicable. 88

Thank you. Questions? arlynn@therapyandmore.net In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 89