Surviving Sepsis Campaign Embraces Sepsis-3 Definition

The 2017 Surviving Sepsis Campaign (SSC) guidelines to be published in the March 2017 issue of Critical Care Medicine* have adopted the 2016 Sepsis-3 definition of sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” discarding the Sepsis-2 definition of sepsis as SIRS due to infection. It now makes no distinction between sepsis and severe sepsis. The SSC guidelines are the recognized clinical authority for the diagnosis and management of sepsis, severe sepsis and septic shock since 2002.

Sepsis-3 defines organ dysfunction as an increase in the total SOFA score by 2 points or more from baseline. SOFA classifies 6 organ systems on a scale from 0 to 4 points using objective measures:

1	Respiratory	pO2/FIO2 ratio
2	Coagulation	Platelet count
3	Liver	Bilirubin
4	Cardiovascular	Mean arterial pressure or vasopressors
5	CNS	Glasgow Coma Scale
6	Renal	Creatinine or urine output

Unfortunately, the CMS Hospital Inpatient Quality Reporting (IQR) severe sepsis management measure (called SEP-1), which is abstracted by the hospital’s Quality Department, defines severe sepsis as SIRS due to infection with acute organ dysfunction. SIRS is defined as 2 or more of 4 criteria: temperature, leukocytosis, tachycardia, and tachypnea. The SEP-1 measure definition of organ dysfunction definition is much different than SOFA.

If providers do not follow the SEP-1 treatment requirements when the SEP-1 organ dysfunction criteria are met, a deficiency in the quality of care for severe sepsis management will be reported. Following only the Sepsis-3 definition may allow many cases to “fall through the cracks” for SEP-1 reporting.

It remains to be seen how CMS will now react to the new SSC guidelines including the adoption of the Sepsis-3 definition which conflicts with the IQR SEP-1 standards. In the meantime, hospitals should make sure medical staff leadership is engaged with this complex challenge of reconciling authoritative clinical guidelines with the CMS quality reporting imperative.

What Should We Do?

CDI and coding professionals should begin using the Sepsis-3 definitions and SOFA criteria on March 1 for queries and clinical validation. Providers can expect auditors to use the Sepsis-3 definitions and criteria for the clinical validation of sepsis; successful appeal will now be unlikely unless SOFA criteria are met.
The Sepsis-3 definition requires acute organ dysfunction as part of the definition of sepsis. Therefore, all cases which meet the Sepsis-3 definition would apparently be coded as severe sepsis.
Hospital quality departments must move quickly with medical staff and leadership to educate and develop a strategy for diagnosis and management that will comply with the CMS IQR.

References: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.

Coding of Pneumonia with COPD

In its 2016 Third Quarter edition, Coding Clinic clarified the use of the following two ICD-10 codes:

J44.0: Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.1: Chronic obstructive pulmonary disease with (acute) exacerbation

COPD and Pneumonia: Code J44.0 requires that the lower respiratory infection be sequenced after it, meaning the lower respiratory infection cannot be assigned as principal diagnosis in patients with COPD whether an acute exacerbation is present or not.

Controversy has swirled over whether pneumonia and influenza are classified as lower respiratory infections because Tabular entries seem to conflict. Includes notes at category J44 list only infections of the bronchial tree and not pneumonia or influenza.

However, the titles of ICD-10-CM acute respiratory infection categories suggest that pneumonia and influenza are lower respiratory infections since they are not “upper” respiratory infections and category J20-J22 is titled “other”:

J00-J06 = Acute Upper Respiratory Infections (includes tracheitis)

J09-J18 = Influenza and Pneumonia

J20-J22 = Other Acute Lower Respiratory Infections (bronchitis, bronchiolitis, and other)

Coding Clinic has settled the controversy by stating that acute bronchitis and pneumonia are included in code J44.0 (lower respiratory infections), but influenza is not since it involves both upper and lower respiratory infections.

Therefore, when a patient is admitted with pneumonia and has COPD, code J44.0 is coded first, followed by the code for pneumonia, and assigned to DRG 190 COPD with MCC.

AECOPD and Pneumonia: When a patient has both pneumonia and acute exacerbation of COPD, it is appropriate to assign both codes J44.0 [COPD with acute lower respiratory infection] and J44.1 [COPD with (acute) exacerbation]. Either of these codes may be sequenced first, based on the reason for the admission.

Aspiration pneumonia and COPD: Based on ICD-10-CM, aspiration pneumonia / pneumonitis is not an acute lower respiratory infection but rather classified as a lung disease due to external agents. Therefore, if the patient has aspiration pneumonia and COPD, aspiration pneumonia (J69.0) would be coded as principal diagnosis if it is the reason for admission, not J44.0.

Summary: Like it or not, Coding Clinic advice in this case is definitive since it provides official coding clarification when ICD-10-CM is ambiguous or conflicting. Even though pneumonia and influenza are classified together in ICD-10-CM, the issue is ambiguous and this Coding Clinic advice has a reasonable basis.

To enshrine this Coding Clinic advice about J44.0 in ICD-10-CM, it would seem prudent for the ICD-10 Coordination and Maintenance Committee to add an Includes note at J44.0 for the pneumonia code categories J12-J18 and for “other” lower respiratory infection categories J20-J22.

Keep in mind that ICD-10-CM clearly does not classify aspiration pneumonia (J69) as a lower respiratory infection and to do so would require adding it as an Includes note at J44.0. ICD-10-CM is not ambiguous or conflicting on this.