International Panel Asserts
SIRS + Infection Does NOT Equal Sepsis
On March 29, 2012, HCPro broadcast an audioconference designed to help coding professionals, Clinical Documentation Improvement professionals and medical professionals understand the proper way to address sepsis in the medical record and how to avoid the trap of inappropriate billing for sepsis DRGs.
Recognizing that the definitions of the 995.9x series of codes and the Official Coding Guidelines regarding the concept of SIRS in the face of infection are faulty, Robert S. Gold, MD gathered information from the medical literature and gained the support of nationally known experts in the field of sepsis.
He engaged David Talan, MD, Professor of Medicine at UCLA School of Medicine, Chair of the Department of Emergency Medicine, Olive View-UCLA Medical Center and Faculty, Division of Infectious diseases to discuss the practical aspects of identifying patients who are sick and at risk of dying from severe infectious processes.
Dr. Talan reviewed his experience and that of others in trying to utilize the SIRS criteria as a means of identifying if patients were at risk on initial triage in the Emergency Department. He noted that so many more patients with minimal infections or patients with noninflammatory processes such as congestive heart failure demonstrated two or more of the SIRS criteria than patients who were, indeed, septic that the SIRS criteria were of no benefit in predicting sepsis. He did confirm that a physician’s senses should be piqued if a sick patient were seen who did demonstrate white count deviations or variations in vital signs so that attention could be turned to evaluating if an inflammatory process was going on and, in that light, the criteria are valuable as a triage tool but nothing more. His editorial entitled “Dear SIRS: It’s time to return to sepsis as we’ve known it” attracted national discussion.
Joining the discussion from London, England was Dr. Jonathan Ball, lecturer in Intensive Care Medicine who works both on the general adult and neuro Intensive Care Units at St. George’s Hospital, the university teaching hospital for southwest London and is on the Advisory Board of the professional journal Critical Care.
Dr. Ball wrote the definitive article summarizing the 2002 international meeting designed to evaluate the then current definition of sepsis and provide insights as to the value of the SIRS criteria. At our conference, he provided insights as to the workup of the patient, who had been admitted through the Emergency Room, from the intensivist’s perspective and how his experience and that of others has led to the conclusion that the SIRS criteria alone may be a valuable screening tool to look further, but that virtually all patients in the critical care arena demonstrated vital sign or laboratory values that would meet the SIRS criteria, regardless of the cause of the abnormalities. From the viewpoint of a physician whose reimbursements are based on how sick the patient is determined by means other than ICD codes or E&M levels, he finds it perverse that SIRS should drive increased payments when that alone provides no evidence that the patient is even sick - that a constellation of variations in vital signs is not equivalent to “sepsis,” a condition that he knows carries significant potential for progression to organ failures and death.
Dr. Gold presented published statements of Dr. Jean Louis Vincent, Head of Faculty, Department of Intensive Care, Erasme University, Brussels, Belgium, Secretary General of the World Federation of Societies of Critical Care Medicine, Editor in Chief of Critical Care and a participant in the 2002 international forum that attempted to put “Sepsis” into focus and to aid the intensivist in identifying patients who were at risk. He had been publishing since 1997 his own frustration with SIRS as a purported substitute for sepsis with such statements as, “Dear SIRS, I’m sorry to say I don’t like you.”
The hope of this presentation was to help the audience recognize that it is more important to see the patient in order to try to make a determination as to how sick that patient is and not to rely on vague variances in vital signs or white blood cell count – to help the CDI specialist to not rely on vital sign variations to attempt to coerce medical staff cooperation in inappropriately reflecting a sick patient by documenting “meets two of the four criteria of SIRS” when the vital sign variances had nothing to do with an inflammatory process or where the infection was truly not at the point of representing sepsis – to help the medical staff or midlevel providers understand that the practice of medicine is a bedside process and that clinical evaluation should lead to ethical and knowledgeable documentation of findings and thought processes.
Jennifer Avery, CCS, CPC-H, CPC, CPC-I, a senior regulatory specialist with the hosting HCPro of Danvers, MA and author of warnings to coding professionals regarding documented SIRS or sepsis (where the clinical course did not seem to support these conditions) presented the background for the proper coding of infections or noninfectious inflammatory processes that might drive a systemic response and the official guidelines and Coding Clinic advice on how to handle these conditions in ICD-9-CM codes. It became obvious that some of the definitions are truly inadequate now, as we have become more sophisticated in the workup of the sick patient and that the mandate to assign codes for sepsis when the patient’s presentation is obviously inconsistent with sepsis is not appropriate and should be updated.
Interestingly, several audience participants reflected in the Q&A session that they have been denied payment for various sepsis discharges when the payer recognized that the patients were not sick, supporting the conclusions and advice of our panel.