Is it sepsis?

John Doe was brought to the emergency department by ambulance from a local nursing home.


John Doe was brought to the emergency department by ambulance from a local nursing home. Nursing home staff reported that the patient developed a temperature of 102°F (38.8°C), pulse of 100 beats/minute, respiratory rate of 20 breaths/minute, blood pressure of 95/60 mm Hg and mental status change in the past 24 hours. The ED physician's examination verified these findings. Urine analysis showed many white blood cells, 3+ bacteria and positive nitrite. Complete blood count showed white blood count of 12,500 cells/mm3 with left shift (WBC 20% bands). Chest x-ray was negative. Serum creatinine concentration was 1.9 mg/dL, up from 1.0 mg/dL reported two weeks before the ED visit. Blood cultures were drawn, urine culture was obtained and intravenous antibiotics were started in conjunction with intravenous fluids.

John Doe's admitting blood pressure dropped to 60/40 mm Hg and did not respond to fluid challenge. Vasopressors were required to maintain blood pressure. Two days later, the family requested comfort care only. The physician documented their request and changed the orders to reflect it. The patient died on the fifth day in the hospital.

The physician's choice of words in documenting this patient's diagnoses will have a significant impact on the attending physician's quality and utilization profile. Consider the following scenarios and how coding and reimbursement change according to the physician's documentation. Each scenario lists a principal and secondary diagnosis along with the corresponding Medicare Severity Refined Diagnostic-Related Group (MS-DRG) payment. Reimbursement rates given are calculated on a hospital-specific rate of $5,500 typical for a community hospital.

Scenario 1

Principal diagnosis: Urosepsis (ICD-9-CM 599.0, 041.4)

Secondary diagnosis: Acute renal insufficiency (ICD-9- CM 593.9)

MS-DRG 690, kidney and urinary tract infections without major complication/comorbidity: $4,170

The geometric mean length of stay for this MS-DRG is 3.5 days.

To better understand sepsis, physicians should be familiar with several terms and definitions, as standardized by the American College of Chest Physicians and the Society of Critical Care Medicine in 1992. Systemic inflammatory response syndrome (SIRS) refers to widespread inflammatory response (usually systemic) with release of various mediators of inflammation resulting in tissue damage. This can result from infection or from noninfectious causes, such as acute pancreatitis, major trauma and burns. SIRS is considered to be present when patients have more than one of the following:

  • Body temperature >38°C (recently changed to 38.3°C) or <36°C;
  • Heart rate >90 beats/minute;
  • Respiratory rate of >20 breaths/minute or a PaCO2 of <32 mm Hg; and
  • White blood cell count of >12,000 cells/mm3 or <4,000 cells/mm3, or >10% immature neutrophils.

Sepsis refers to infection with SIRS, which does not necessarily have to be proven by positive culture.

The ICD-9-CM code assignment for urosepsis is the same as for a localized urinary tract infection without other findings, i.e. systemic response. In 2003, Official Coding Guidelines introduced new ICD-9-CM codes and guidelines for reporting of sepsis and SIRS, severe sepsis and septic shock consistent with the current medical literature (Coding Clinic, Quarter 4, 2003, pages 79-81; Coding Clinic, Quarter 4, 2006, page 113; Official Coding Guidelines effective October 1, 2008, pages 19-22). Acute renal insufficiency is a nonspecific term that does not count as a complication or major complication. Scenario 1 has a low-paying MS-DRG with the expectation of a short length of stay and low mortality rate.

Scenario 2

Principal diagnosis: Sepsis with SIRS due to urinary tract infection (E. coli in urine) (ICD-9-CM 038.9, 995.91, 599.0, 041.4)

Secondary diagnosis: Acute renal insufficiency (ICD-9- CM 593.9)

MS-DRG 872, sepsis without major complication/comorbidity (MCC) without 96+ hours of mechanical ventilation: $6,164

The geometric mean length of stay for this MS-DRG is 4.7 days.

The severity of sepsis depends on specific organ dysfunction and/or the presence of unstable vital signs (compromised circulation to tissues/organs) that cannot be explained by another condition. Severe sepsis refers to sepsis associated with some sign of organ dysfunction or hypoperfusion, including:

  • Acute renal failure or acute kidney injury or decreased urinary output (<0.5 mL/kg per hour for >2 hours despite adequate fluid resuscitation);
  • Altered mental status change (sudden onset);
  • Lactate level >2 mmol/L;
  • Myocardial or cardiac dysfunction;
  • Mottled skin;
  • Thrombocytopenia (platelet count <100,000/mm3);
  • Respiratory compromise/acute respiratory failure.

The clinical scenario described in the case study supports the principal diagnosis in scenario 2. However, coders may not report diagnoses unless they are clearly documented by the provider responsible for establishing the diagnosis of the patient.

Scenario 3

Principal diagnosis: Severe sepsis with SIRS due to urinary tract infection (E. coli) (ICD-9-CM 038.9, 995.92, 599.0, 041.4)

Secondary diagnosis: Acute renal failure or acute kidney injury (nontraumatic) due to sepsis, MCC (ICD-9-CM 584.9)

MS-DRG 871, severe sepsis with MCC without 96+ hours of mechanical ventilation: $10,022

The geometric mean length of stay for this MS-DRG is 5.5 days.

Septic shock refers to severe sepsis with hypotension despite adequate volume resuscitation. Even though the clinical findings are consistent with severe sepsis and the physician documented severe sepsis, the MS-DRG is not changed to reflect the higher severity of illness unless the secondary diagnosis representing the organ dysfunction or failure is reported using specific terminology such as:

  • Acute respiratory failure (ICD-9-CM 518.81);
  • Acute renal failure or acute kidney injury (ICD-9-CM 584.9);
  • Encephalopathy (specify type).

Scenario 4

Principal diagnosis: Severe sepsis with shock with SIRS due to urinary tract infection (E. coli) (ICD-9-CM 038.9, 995.92, 785.52, 599.0, 041.4)

Secondary diagnosis: Acute renal failure or acute kidney injury (nontraumatic) due to sepsis, MCC (ICD-9-CM 584.9)

Additional diagnoses: Palliative care (V 66.7) MS-DRG 871, severe sepsis with MCC without 96+ hours of mechanical ventilation: $10,022

The geometric mean length of stay for this MS-DRG is 5.5 days.

Documented diagnoses for this patient now establish the severity of illness needed for accurate risk adjustment. The risk of death for the patient described in scenario 4 is significantly higher than for scenarios 1 to 3. Information on evidence-based recommendations for the acute management of sepsis and septic shock can be found in the Surviving Sepsis Campaign's 2008 international guidelines for management of severe sepsis and septic shock (Crit Care Med. 2008;36:296-327).

Clinical perspective for this article was provided by Ali A. Mohammad, FACP, a hospitalist in internal medicine and critical care medicine at Greenville Memorial Hospital in South Carolina. Dr. Mohammad is a member of ACP Hospitalist's editorial advisory board.