R78.81 should not be used to indicate the presence of sepsis. Will the discharge summary supersede the physician’s answer to the query? The terms "septicemia," "bacteremia," and "sepsis" are often used interchangeably by physicians, even though these are not necessarily all describing the same clinical condition. All rights reserved, Research corner: Words that sound like what they are, Q&A: Conflicting documentation of sepsis and bacteremia. ICD-10-CM Official Guidelines for Coding and Reporting directs us that when sepsis or severe sepsis is documented as being associated with a noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious condition should be sequenced first, followed by the code for the resulting infection. Copyright © 2021 HCPro, a Simplify Compliance brand. If different physicians document bacteremia and sepsis, and the documentation conflicts, query the attending physician. Another possibility is that the patient was never truly septic and only had positive blood cultures and the attending’s documentation will lead to accurate ICD-10 code assignment without further query. The clinical truth of that scenario is that sepsis was the principle diagnosis, present, and treated, while the ongoing bacteremia at discharge is still significant enough to require documentation (as the patient may have to be on antibiotic coverage for weeks or even months). Q: My physicians use the term “bacteremia” frequently and are treating it. Many physicians use the terms bacteremia and sepsis interchangeably and often believe that both terms imply the patient has sepsis. Bacteremia is the presence of bacteria in the blood as evidenced by a positive blood culture. I sent a query to clarify which was correct and the attending confirmed bacteremia. When patients have sepsis and bacteremia, and the physician documents both conditions in the medical record, coders can report a code from the 038 series. Bacteremia is the presence of bacteria in the blood, hence a microbiological finding. Septicemia is a systemic disease associated with the presence of pathogenic microorganisms within the blood stream. The code A41.50 is valid during the fiscal year 2021 from October 01, 2020 through September 30, 2021 for the submission of HIPAA-covered transactions. Sepsis vs bacteremia Medical Billing and Coding Forum. Clinically, the physician may not be differentiating the diagnoses as two different things, even though coding does. I sent a query to clarify which was correct and the attending confirmed bacteremia. 20. Physicians should use the term “bacteremia” if there is evidence of bacteria circulating in the blood. Q: I recently was reviewing a chart where the infection control physician stated the patient had sepsis, but the attending listed bacteremia as the diagnosis. • Septicemia – Choose a code from 038.xx (Septicemia) depending on the information given. However, keep in min… Severe sepsis with septic shock: R7881: Bacteremia: MECHANICAL VENTILATION >96 HOURS. This explains why the physician answered the way he did, but this won’t allow the coders to code the record appropriately. The medical record reports that his skin was cool and clammy. Septicemia is also known as blood poisoning. There are however, all sorts of nuances to this. When bacteria are present in the blood, then it is called as bacteremia. Sepsis would. There are no ICD-10-CM official guidelines for coding and reporting that specifically pertain to bacteremia. Sepsis - Coding Guidelines Sepsis may be coded if documented Assign code A41.9 unless the organism for the systemic infection is documented and a code with higher specificity may be assigned. Part of that education should include an explanation that code R78.81, Bacteremia, is a symptom code with an Exclude1 note stating it can’t be used with sepsis and that additional documentation related to the cause of the infection, i.e., gram-negative bacteria, salmonella, etc., would be needed for correct code assignment. Consider also explaining that as a principal diagnosis, the condition of “bacteremia” will not likely meet medical necessity for an inpatient stay. This scenario will occasionally result in a legitimate need for an admission as IV antibiotics are required to clear the blood stream and there is no viable alternative to admission to the patient’s insurance (or lack of) and their socio-economic circumstances. updated definitions and clinical criteria for sepsis were published in the February 2016 issue of the Journal of the American Medical Association (JAMA). Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. Coding tips: According to AHA Coding Clinic™ , second quarter 2011, if bacteremia is associated with a local infection, the local infection is coded first, followed by the bacteremia, … When both bacteremia and sepsis are documented, code only sepsis. Since ICD-10 utilizes combination coding, sepsis without acute organ failure requires only one code, that is, the code for the underlying systemic infection (A40.0 – A41.9). Coding Clinic Guidance • Answer: Assign code 038.12, MRSA Septicemia, as the principal diagnosis since it was POA and is the systemic infection. Allen Frady, RN, BSN, CCDS, CCS, CRC, This definition gives more weight to organ dysfunction and less to SIRS criteria (Sepsis-2 definition) in identifying potential sepsis cases. ICD 10 code for Sepsis and Septicemia – A41.9. In this series, we will learn what sepsis is or causes of sepsis, how to sequence the diagnosis in ICD-10-CM, what are the clinical indicators for sepsis, is a query necessary before reporting the diagnosis of sepsis… Corresponding to these findings, CRP and IL-6 levels and mortality were significantly higher in patients with septic shock when compared with either sepsis patients or severe sepsis patients. If sepsis is likely to develop, a patient with bacteremia will most likely receive antibiotics through an IV line. The inflammation in sepsis can produce blood clots and leaking blood vessels. Assign codes 995.91, Sepsis, 730.17, Chronic osteomyelitis, ankle and foot, 585.6, ESRD, and V45.11, Renal dialysis status, as additional diagnoses. Coding Septicemia, SIRS, and Sepsis AHIMA 2008 Audio Seminar Series 11 Notes/Comments/Questions SIRS vs. Sepsis Sepsis: This is a systemic inflammatory response to a documented infection. It may be primary (without an identifiable focus of infection… Septicemia is defined as a condition caused by the presence of bacteria, fungi, viruses, or other pathogenic organisms in the bloodstream with no indication that sepsis exists. Sepsis: Bacteremia or another infection triggers a serious bodywide response , which typically includes fever, weakness, a rapid heart rate, a rapid breathing rate, and an increased number of white blood cells. In Chapter 1 the code range A40 – A41.9, classifies several types of bacterial sepsis but also includes “Sepsis, unspecified organism”. Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for HCPro in Middleton, Massachusetts, answered this question. Common reasons for the lack of associated claims codes included coding omission and lack of physician documentation of bacteremia cause. The infection can be due to bacteria in the bloodstream, but sepsis can also be produced by an infection that is present only in one part of the body, such as the lungs in pneumonia. Aapc.com DA: 12 PA: 45 MOZ Rank: 58. Will the discharge summary supersede the physician’s answer to the … For example, the patient may have initially been septic with positive blood cultures and no longer has indicators for sepsis upon discharge, but they may still have a positive repeat blood cultures. The response also affects many internal organs, such as the kidneys, heart, and lungs, which begin to fail. Contact him at AFrady@hcpro.com. Fever can certainly rise, but in some people, especially children, this is the only symptom. Not every patient with positive blood cultures is septic. That is an additional reason to begin to query physicians for sepsis rather than septicemia when it is appropriate. The manifestations of sepsis are the same as those previously defined for SIRS. Or, better yet, what query should I be sending? For information regarding CDI Boot Camps, click here. When people have sepsis, healthcare professionals often describe this as bacteria in the blood or a blood infection. All rights reserved, ACDIS update: Introducing the Physician PRO, Q&A: How to handle physicians who keep using the term ‘bacteremia’. Q: I recently was reviewing a chart where the infection control physician stated the patient had sepsis, but the attending listed bacteremia as the diagnosis. Sepsis is a clinical diagnosis needing further specification regarding focus of infection and etiologic pathogen, whereupon clinicians, epidemiologists and microbiologists apply different definitions and terminology. Is sepsis also present? Mr. Remier, a 72-year-old was admitted from a skilled nursing facility on 9/10/19, presented with a fever of 101, with a respiratory rate of 110. A task force of leading sepsis experts introduced a new definition for sepsis and septic shock in 2016 known as Sepsis-3. Even though bacteremia and sepsis are closely related, they are two separate conditions. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1. The treatment includes IV antibiotics. On the discharge summery, though, sepsis was still listed. • Septicemia used to mean the presence of multiplying bacteria in the blood while bacteremia means the presence of bacteria in the blood. Part of that education should include an explanation that code R78.81, Bacteremia, is a symptom code with an Exclude1 note stating it can’t be used with sepsis and that additional documentation related to the cause of the infection, i.e., gram-negative bacteria, salmonella, etc., would be needed for correct code assignment. For information, contact her at sbrodie@hcpro.com. A. Pasbjerg Date: January 30, 2021 A dish of klebsiella oxytoca bacteria, which can cause sepsis.. Next month, in Part 2, we'll delve into the conflicts and contradictions that exist within current sepsis literature, research, and other professional diagnostic standards. Shelia Bullock, RN, BSN, MBA, CCM, CCDS Director, Clinical Documentation Improvement University of Mississippi Health Care 2500 North State Street Room H139 Copyright © 2021 HCPro, a Simplify Compliance brand. This is because our immune system clears it immediately if it comes. What should they be calling it? Remember the clinical validation of sepsis is always of utmost importance as not every patient with sepsis indicators is septic. A: Believe it or not, in many situations, attendings use the term “bacteremia” to imply sepsis. When assigning a code for SIRS and Severe Sepsis, Chapter 18 is where the codes are located: R65.1 Systemic inflammatory response syndrome (SIRS) of non-infectious origin. The result is that you may actually have to place a second query to confirm the physician does not indeed mean sepsis when he answered “bacteremia.”. So, physician education will likely need to be your first step. Progress note from today states that his blood cultures were positive but with no source of infection identified. A query will have to be placed to get this fully clarified so that sepsis can be reported. • Septicemia was replaced by better terms that suggest the actual clinical condition of the patient but bacteremia is still around. Sepsis … Bacteremia is defined as the presence of viable bacteria within the liquid component of blood (blood infection). or if we were given bacteremia R78.81 bacteremia and A41.51 sepsis … Bacteremia is the presence of bacteria in the blood, hence a microbiological finding. If not you’re left with a conundrum: You have a patient who is sick with localized infection with bacteremia and we are treating it with the same fervor as sepsis, but it is not considered sepsis. DRG 870 SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS. A: This is a very common scenario and often requires substantial physician education to change documentation behaviors. In the claims cohort, there were 150 CLABSIs among 150 patients, and 65.3% of these cases were discordant with NHSN criteria. The term bacteremia only refers to the presence of bacteria in the bloodstream and not the infectious process. Central Line-Associated Bloodstream Infection Based on current coding advice and coding directives, code 999.32, Bloodstream infection due to central venous catheter, followed by code 790.7, Bacteremia, should be assigned for bacteremia due to a peripherally inserted central catheter (PICC) line. Based on the above information, could you please clarify the diagnosis you are treating. In this month's column, we will explore the current diagnostic standards for sepsis, severe sepsis, and septic shock as well as coding considerations. The confusion between bacteremia vs sepsis comes from how these conditions are commonly described to patients. The clinical features include 2 or more of the of the conditions listed under Here’s an example of what a query might look like, bearing in mind that the specifics of the encounter as documented in the medical record would need to be included. This is part 1 in a series focused on coding of sepsis. Additionally, physicians don’t know about the differences in coding rules related to these conditions and the affect that their documentation may have on code assignment. Sepsis remains one of the most common diagnoses reported, but is also one of the most common found in denials. Bacteremia can progress to septicemia, but only when there is a more infectious process going on with the patient. On the discharge summery, though, sepsis was still listed. 2 Documentation of bacteremia with clinical signs and symptoms of a systemic infection such as fever, chills, or tachycardia should be clarified with the provider to ensure proper code assignment. A third possible scenario is that when the attending says “bacteremia,” he or she actually means “sepsis with positive blood cultures.” In which case, you need not only another query, but also to provide education for the physician. – also assign 995.9X (Sepsis or Severe Sepsis) No. Septicemia Vs Bacteremia. It’s important to remember that bacteremia by the coding definition does not generally meet medical necessity for an inpatient admission because it implies the patient is asymptomatic with a self-limiting condition that requires little to no treatment. •acteremia – B Code 790.7 (Bacteremia); use an additional code to identify causative organism (041.x, Bacterial infection in conditions classified elsewhere and of unspecified site). It is often transient and of no consequence; however, sustained bacteremia may lead to widespread infection and sepsis. In a normal scenario, there will be no bacteria in the blood. The simple presence of bacteria in the blood is known as bacteremia. Bacteremia and sepsis are common problems in clinical practice. Last updated: October 26, 2018 by Sagar Aryal Bacteremia is the simple presence of bacteria in the blood while Septicemia is the presence and multiplication of bacteria in the blood. Early symptoms of bacteremia include chills and a fever that generally is at least 101 degrees F (38.33 degrees C). The patient may be febrile and receiving antibiotics, but they cannot figure out a source. If anyone can help on clarifying the Diagnosis coding for sepsis vs bacteremia; I know we can't code them together, but if we were given both diagnosis bacteremia R78.81 and A41.9 unspecified sepsis which one do we code? The Official Guidelines for Coding and Reporting, Section I.C.1.d.1.a, instruct us to “assign the appropriate code for the underlying systemic infection, if the type of infection or casual organism is not further specified, assign code A41.9, Sepsis, unspecified organism.”. answered this week's question. This simplified definition is essentially the same as bacteremia or septicemia. – 038.xx code is sufficient Tip! Now, bacteremia is the principal diagnosis, it won’t change your DRG, though it could certainly affect quality concerns and medical necessity. The ICD-10-CM code for bacteremia, R78.81, can be found in Chapter 18, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings. There are many “false positives” which may occur due to the patient’s pre-existing disease states as well as confounding factors from other new onset acute conditions which must be considered properly in the context of the patient. Query physician to verify that no diagnosis of Sepsis … In ICD-9, there were codes whose description included the word "septicemia," but that word does not appear in the corresponding ICD-10 codes. The ICD-10-CM code A41.50 might also be used to specify conditions or terms like bacteremia, bacteremia caused by gram-negative bacteria, sepsis due to gram negative bacteria or severe sepsis with acute organ dysfunction … the sepsis? Bacteremia and sepsis are common problems in clinical practice. 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