Ask Dr. Pinson

Readers inquire about sepsis criteria, uncontrolled diabetes, and aspiration pneumonia.


Q: My academic institution has adopted the Sepsis-3 criteria to diagnose sepsis for billing purposes. When CMS does not recognize these yet, what are your thoughts on utilizing the Sequential Organ Failure Assessment (SOFA) criteria to avoid audits?

Image by Getty Images
Image by Getty Images

A: Actually, CMS does not “endorse” or “recognize” any particular diagnostic standards or criteria other than stating that diagnoses must be substantiated by criteria that are widely accepted by the medical community. The most authoritative standards come from diagnostic criteria and guidelines published by medical professional societies and organizations.

The authoritative source for the clinical definition, diagnosis, and management of sepsis and severe sepsis is the Surviving Sepsis Campaign (SSC), which has adopted the Sepsis-3 definitions and criteria (based on changes in SOFA score).

However, the CMS Hospital Inpatient Quality Reporting (IQR) performance measure for sepsis (SEP-1) uses the National Quality Foundation #0500 sepsis management bundle for severe sepsis. This measure bases the diagnosis of sepsis on a selected number of systemic inflammatory response syndrome (SIRS) criteria from the Sepsis-2 definition rather than Sepsis-3 criteria.

For clinical purposes, the authoritative diagnostic standard is now Sepsis-3, even though many clinicians have been unwilling to adopt it in their own practices. However, SIRS criteria from Sepsis-2 must be used to identify patients for initiation of the CMS SEP-1 IQR management bundle. Sepsis-3 defines sepsis (“severe sepsis”) as at least a two-point change from baseline SOFA score caused by an infection. The SOFA table would be the basis for authoritatively establishing the diagnosis of sepsis.

Q: One diagnostic standard for diabetes is an HbA1c of 6.5% or higher. Is there an HbA1c to diagnose uncontrolled diabetes?

A: One diagnostic criterion for diabetes is hyperglycemia defined as a fasting blood glucose level greater than 140 mg/dL, which is therefore considered uncontrolled. ICD-10-CM indicates that hypoglycemia (blood glucose level <70 mg/dL) may also be considered uncontrolled. However, ICD-10-CM assigns “uncontrolled” diabetes to an uncomplicated diabetes code (e.g., E11.9 for type 2) unless the condition is further specified as hyperglycemia (e.g., E11.65) or hypoglycemia (e.g., E11.649), both considered diabetic complications. Identifying diabetic complications is important since they contribute to greater severity of illness classification, which impacts quality measures and reimbursement.

An HbA1c level of 6.5% or above would meet the diagnostic criteria for diabetes, and some treatment guidelines indicate that the HbA1c level should be reduced below 6.5% for adequate control. Therefore, an HbA1c level of 6.5% or above might be considered uncontrolled. But, as noted above, “uncontrolled” must be further specified as hyperglycemia or hypoglycemia, so an elevated HbA1c level alone will be assigned the unspecified code (e.g., E11.9).

Q: With recent updates in coding guidelines (Coding Clinic, Third Quarter 2016, pages 15-16), our coding department is saying that a patient admitted with “sepsis due to aspiration pneumonia” will have aspiration pneumonia as the primary diagnosis and not sepsis. Their reasoning is that aspiration pneumonia is a noninfectious process unless it is clearly specified that bacterial pneumonia was caused by the aspiration. They are recommending documenting “sepsis due to gram-negative bacteria pneumonia due to aspiration.” Is that correct?

A: No, the instructional note you're referring to (for code J44.0) is applied to chronic obstructive pulmonary disease (COPD) and lower respiratory infections. Its instruction to “use additional code to identify the infection” does not apply to aspiration pneumonia. The ICD-10-CM code for aspiration pneumonia does not fall in the “respiratory infection” codes. It is code J69.0, pneumonitis due to inhalation of food and vomit, under “lung diseases due to external agents.”

If a patient has both COPD and aspiration pneumonia, assign codes J44.9 for chronic obstructive pulmonary disease, unspecified, and J69.0. The sequencing of the two conditions will depend on the circumstances of admission.

This coding provision is not found with reference to sepsis. Two additional points on sepsis and aspiration pneumonia are as follows:

  • If aspiration pneumonia is considered infectious, sepsis must be assigned as the principal diagnosis.
  • If aspiration pneumonia is not considered infectious, then a code for sepsis cannot be assigned at all since the diagnosis of sepsis requires an underlying infectious cause.

Most inpatients with aspiration pneumonia have signs and symptoms of bacterial infection, usually due to anaerobic bacteria. It is my professional opinion that if an inpatient with “aspiration pneumonia” is treated for at least seven days with antibiotics active against anaerobes, it is an infectious process and should be coded as such. The ICD-10-CM code for aspiration pneumonia (J69.0) is not within the “acute lower respiratory infection” codes (J12-J18 and J20-J22) to which the COPD instruction you mentioned applies.

However, specification of aspiration pneumonia as bacterial (J15.9) or viral (J12.9) places it squarely in the acute lower respiratory infection codes. Clinicians typically use the term “pneumonia” to describe lung infection and “pneumonitis” for lung inflammation without infection, but code J69.0 is used for either aspiration pneumonia or aspiration pneumonitis.