Clinical Guidelines to Support Coding of Sepsis and Septic Shock

POLICY NUMBER

None

DESCRIPTION

Sepsis is a clinical syndrome defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality. Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors and having elevated lactate levels despite adequate volume resuscitation.

Sepsis is a leading cause of death, morbidity, and expense, contributing to one-third to half of deaths of hospitalized patients. According to the Centers for Disease Control and Prevention, the burden of sepsis is high, with over 1.7 million adult sepsis cases annually in the U.S. which contribute to 270,000 deaths. Patients who survive sepsis often suffer long-term physical, psychological, and cognitive disabilities.

Management of sepsis is a complicated clinical challenge requiring early recognition and management of infection, hemodynamic issues, and other organ dysfunctions. Because there is no confirmatory diagnostic test, the diagnosis of sepsis requires clinical judgment based on evidence of infection and organ dysfunction. A 1991 consensus conference established a clinical definition based on the patient’s systemic inflammatory response syndrome (SIRS) to infection (later referred to as Sepsis-1). Four SIRS criteria were defined, namely tachycardia (heart rate >90 beats/min), tachypnea (respiratory rate >20 breaths/min), fever or hypothermia (temperature >38 or <36 °C), and leukocytosis, leukopenia, or bandemia (white blood cells >12,000/mm3, <4,000/mm3 or bandemia ≥10%). Patients who met two or more of these criteria fulfilled the definition of SIRS. These clinical criteria were expanded in 2001 in the Sepsis-2 criteria. The 2001 task force recognized the limitations with these definitions, but did not offer alternatives due to a lack of supporting evidence. However, they did expand the list of diagnostic criteria. In order to be diagnosed with sepsis under the Sepsis-2 definition, as with Sepsis-1, an individual must have at least two SIRS criteria and a confirmed or suspected infection. In effect, the definitions of sepsis and septic shock remained unchanged for more than two decades.

In response to increasing understanding of sepsis pathobiology, a task force updated the clinical definitions in 2016, and in Sepsis-3, defined sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection,” with clinical guidelines defining organ dysfunction as acute change in total Sequential Organ Failure Assessment (SOFA) score ≥2 points consequent to the infection. The new Sepsis-3 definition abandoned use of host inflammatory response syndrome criteria (SIRS) in identification of sepsis and eliminated the term severe sepsis. As part of the 2016 evaluation of criteria for identifying septic patients, the task force compared traditional SIRS criteria to other methods, including the Logistic Organ Dysfunction System (LODS) and SOFA scoring. Based on this analysis, the authors recommended use of SOFA scoring to assess the severity of organ dysfunction in a potentially septic patient. Among critically ill patients with suspected sepsis, the predictive validity of the SOFA score for in-hospital mortality was superior to that of the SIRS criteria (area under the receiver operating characteristic curve 0.74 versus 0.64). Although the predictive capacity of SOFA and LODS were similar, SOFA is considered easier to calculate, and was therefore recommended by the task force.

Other studies have supported the idea that SIRS is not an ideal marker for sepsis. The use of 2 or more SIRS criteria to identify sepsis was unanimously considered by the task force to be unhelpful. Changes in white blood cell count, temperature, and heart rate reflect inflammation, the host response to “danger” in the form of infection or other insults. The SIRS criteria do not necessarily indicate a dysregulated, life-threatening response. Furthermore, SIRS criteria are present in many hospitalized patients, including those who never develop infection and never incur adverse outcomes. The Sepsis-3 definition of sepsis reflects an up-to-date view of pathobiology, particularly in regard to what distinguishes sepsis from uncomplicated infection.

A higher SOFA score is associated with an increased probability of mortality. The score grades abnormality by organ system and accounts for clinical interventions. However, laboratory variables, namely, PaO2, platelet count, creatinine level, and bilirubin level, are needed for full computation. The baseline SOFA score should be assumed to be zero unless the patient is known to have preexisting (acute or chronic) organ dysfunction before the onset of infection. Patients with a SOFA score of 2 or more had an overall mortality risk of approximately 10% in a general hospital population with presumed infection. This is greater than the overall mortality rate of 8.1% for ST-segment elevation myocardial infarction, a condition widely held to be life threatening by the community and by clinicians. Depending on a patient’s baseline level of risk, a SOFA score of 2 or greater identified a 2- to 25-fold increased risk of dying compared with patients with a SOFA score less than 2.

The predominant score in current use is SOFA. The SOFA score is not intended to be used as a tool for specific patient management but as a means to clinically characterize a septic patient. The SOFA score is designed not only to predict outcome but also to describe a progressive sequence of complications in the critically ill.

No scoring tool defines the diagnoses that are reportable on an inpatient hospital claim. The ICD-10-CM Official Guidelines for Coding and Reporting, FY 2020 ( https://www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf ) define what diagnoses are reportable.  Except where the ICD-10 alphabetical index offers a specific code for an “impending” condition, diagnoses that are prevented from developing are not coded as if they existed.

POLICY

To clinically characterize a patient as septic AND file a sepsis ICD-10 diagnosis code (See Policy Guidelines) on a claim, the medical records must support an acute increase of  > 2 SOFA points from baseline from 48 hours before and up to 24 hours after onset of infection using the assessment criteria below:

Sequential [Sepsis-Related] Organ Failure Assessment (SOFA)

Abbreviations: FIO2, fraction of inspired oxygen; MAP, mean arterial pressure; PaO2, partial pressure of oxygen. Catecholamine doses are given as μg/kg/min for at least 1 hour.

Glasgow Coma Scale scores range from 3–15; higher score indicates better neurological function.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

Sepsis and Septic Shock ICD-10 Diagnosis Codes

POLICY HISTORY

New policy added: 11/26/2019

SOURCE(S)

Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, Hospital Toolkit for Adult Sepsis Surveillance, March 2018 https://www.cdc.gov/sepsis/pdfs/Sepsis-Surveillance-Toolkit-Mar-2018_508.pdf

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., … Angus, D. C. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 801–810. doi:10.1001/jama.2016.0287                                                        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968574/

Marik, P. E., & Taeb, A. M. (2017). SIRS, qSOFA and new sepsis definition. Journal of thoracic disease, 9(4), 943–945. doi:10.21037/jtd.2017.03.125 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5418298/

Howell MD, Davis AM. Management of Sepsis and Septic Shock. JAMA. 2017;317(8):847–848. doi:10.1001/jama.2017.0131    https://www.ncbi.nlm.nih.gov/pubmed/28114603

Vincent, J.L et al (1996). The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996 22:707-710.                                                                                                                                                                              https://www.ncbi.nlm.nih.gov/pubmed/8844239

CODE REFERENCE

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