Strategies for Sepsis Complications and Correct Procedure Capture

“Strategies for Sepsis, Complications and Correct Procedure Capture” October 23, 2019 1

Speaker Bio’s Deborah Gardner-Brown, Dr. Keith I. Stokes RHIT, CCS, C-CDI, CI-CDI, CDIP, CCDS, CCMSCP, CPMA • Ms. Gardner-Brown is a Subject Matter Expert, Speaker, DRG Dispute Resolution Examiner, and experienced Auditor for the acute and outpatient care settings. She is also an AHIMA approved ICD-10 -CM/PCS Trainer that has developed and presented educational material on several ICD-10 -CM/PCS and CDI topics. • Ms. Gardner-Brown has more than 30 years experience in both hospital and professional coding, clinical documentation improvement, denials management, and revenue cycle integrity. • Deborah is the founder of Sepsis Integrity Review Services, and Principal Consultant for Reimbursement Review Associates, Inc. • Dr. Keith I. Stokes is a board-certified physician with a diverse career that includes experience as a clinic medical director, hospital chief of staff, and hospitalist medical director, consultant and physician advisor. • Dr. Stokes is a graduate of Meharry Medical College in Nashville, Tennessee. He completed internship and a residency in Family Medicine at the University of Mississippi Medical Center in Jackson, Mississippi. Dr. Stokes has served as a consultant for numerous hospitals, primarily focused in the areas of utilization management and clinical documentation improvement. • Dr. Stokes acquired Docu. Comp® LLC in April of 2017 after working with them for several years as a physician advisor. He is a certified Physician Advisor Clinical Documentation Improvement & Integrity instructor. Sepsis Integrity Review Services 2019 2

Abstract • Sepsis is a highly scrutinized medical condition that should be identified specifically in terms of the type of sepsis, the etiology of the sepsis if known, and the treatment(s) provided to the patient. Sepsis is most often linked to a localized infection, and or as a complication resulting from a procedure, or as a complication of an injury/trauma. • The payments for these acute, high risk sepsis cases will vary widely depending on the type/etiology of the sepsis, and the various procedures that may be performed to diagnose, treat, and or eradicate both the localized and systemic infection. Correct payment, compliant coding, and successful appeals will depend on a complete understanding of the code selections for the sepsis diagnosis, and the precise documentation necessary for the sepsis, infection(s), and the procedures performed on the patient. Sepsis Integrity Review Services 2019 3

Objectives • Review the I-10 -CM diagnoses options for sepsis, post-operative shock, and post traumatic sepsis code assignments Review • Compare MS-DRG and APR-DRG Sepsis DRGs Compare • Examine various I-10 -PCS root operations, body parts, and procedural approaches to demonstrate different DRG/APR impacts. Examine Identify Sepsis Integrity Review Services 2019

6 DRG Blocks for MDC 18 For MS-DRGS Sepsis and Other Infectious & Parasitic Diseases • Medical DRGs • Surgical DRGs 4 Blocks 2 Blocks Postoperative and Post-Traumatic Infections 862 -863 Infections and Parasitic Diseases with listed Procedure 853 -854 -855 Other Infectious and Parasitic Disease Diagnoses 867 -868 -869 Postoperative or Post-Traumatic Infections with Procedure 856 -857 -858 Septicemia or Severe Sepsis Mechanical ventilator 870 -871 -872 ©RRA, Inc. 2019 5

MDC 18 Infectious & Parasitic Diseases, Systemic or Unspecified Sites SEPSIS • DRG 870 SEPTICEMIA OR SEVERE SEPSIS WITH MV 96+ HOURS • DRG 871 SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV 96+ HOURS WITH MCC • DRG 872 SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV 96+HOURS WITHOUT MCC Sepsis 2019 6

A 021 Salmonella sepsis A 4151 Sepsis due to Escherichia coli [E. coli] A 207 Septicemic plague A 4152 Sepsis due to Pseudomonas A 227 Anthrax sepsis A 267 Erysipelothrix sepsis Sepsis/Shock DRGs 870 -872 Principal Diagnoses = ONLY 43 Codes A 327 Listerial sepsis A 4153 Sepsis due to Serratia A 4159 Other Gram-negative sepsis A 391 Waterhouse-Friderichsen syndrome A 4181 Sepsis due to Enterococcus A 392 Acute meningococcemia A 4189 Other specified sepsis A 393 Chronic meningococcemia A 419 Sepsis, unspecified organism A 394 Meningococcemia, unspecified A 427 Actinomycotic sepsis A 3989 Other meningococcal infections A 399 Meningococcal infection, unspecified A 400 Sepsis due to streptococcus, group A A 5486 Gonococcal sepsis B 007 Disseminated herpes viral disease A 401 Sepsis due to streptococcus, group B B 377 Candidal sepsis A 403 Sepsis due to Streptococcus pneumoniae R 571 Hypovolemic shock A 408 Other streptococcal sepsis R 578 Other shock A 409 Streptococcal sepsis, unspecified R 6510 Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction A 4101 Sepsis due to Methicillin susceptible Staphylococcus aureus A 4102 Sepsis due to Methicillin resistant Staphylococcus aureus R 6511 Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction A 411 Sepsis due to other specified staphylococcus R 6520 Severe sepsis without septic shock A 412 Sepsis due to unspecified staphylococcus R 6521 Severe sepsis with septic shock A 413 Sepsis due to Hemophilus influenzae R 7881 Bacteremia A 414 Sepsis due to anaerobes A 4150 Gram-negative sepsis, unspecified ©RRA, Inc. 2019 7

Sepsis Integrity Review Services 2019 8

Section II. Selection of Principal Diagnosis H. Uncertain Diagnosis CMS Official Coding and Reporting Guidelines 2020 • II. H. If the diagnosis documented at the time of discharge is qualified as “probable, ” “suspected, ” “likely, ” “questionable, ” “possible, ” or “still to be ruled out, ” “compatible with, ” “consistent with, ” or other similar terms indicating uncertainty, code the condition as if it existed or was established. • The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. • Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals. Sepsis Integrity Review Services 2019 9

Sepsis Impact on Organ Systems/ Circulatory/Metabolic Functions System Normal Abnormal Potential Conditions Other Risk Factors Respiratory Rate <20 Rate >20 Acute Resp Failure Asthma, COPD Renal Creatinine <2. 0 Creatinine > 2. 0 Acute Renal Failure CKD, Dehydration Metabolic Lactate Normal Lactate >Normal Lactic Acidosis Seizures, Trauma Central Nervous System GCS >14 GCS<14 Encephalopathy, Coma Seizure, Dementia Circulatory MAP >65 Pulse <100 MAP<65 Pulse >100 Septic Shock Tachycardia Arrhythmias, ACS Hematologic WBC >4 or <12 WBC <4 or>12 Leukocytosis, Leukopenia Leukemia, Immunodeficiency Sepsis Integrity Review Services 2019 10

Very Specific Documentation is Needed for Coding Specific Type of Sepsis Etiology (due to – resulting from- as a result of) Cause and effect Relationship Location of underlying Localized infection Acuity of localized Infection Complications and Manifestations Acute Chronic Unspecified (including Drug resistant infections) 11

Sepsis and Localized infection require detailed findings of the cause and effect relationship including the acuity of signs and Symptoms 1 st listed or Principal Diagnosis Infection of Sepsis due to acute infection in body system: Gastrointestinal Pulmonary Cardiac Central Nervous System Skin/Soft tissue Bones Liver/Gallbladder/Pancreas Urinary Bladder/Kidneys Signs & Symptoms : Ø Ø Ø Skin changes Ø Organ system (s) failure-dysfunction (Ren. F, RF, LF, ) Ø Change of mental status/Confusion/Delirium Ø Ø Ø Ø Toxic Encephalopathy Vital signs (HR, Resp, Temp, GCS) Functional loss- eyesight, hearing, sensation Lethargy/weakness/Fall Fever, Chills, Rigors Elevated WBC Lactic Acidosis Tissue necrosis/death Acute localized infection untreated/failed out- patient treatment/non-compliant with treatment Genitourinary ©RRA, Inc. 2019 12

I-10 code All Specifically Named Sepsis Infection Diagnoses are MCC’s Code Description A 021 MCC Salmonella sepsis A 207 MCC Septicemic plague A 227 MCC Anthrax sepsis A 267 MCC Erysipelothrix sepsis A 327 MCC Listerial sepsis A 392 MCC Acute meningococcemia (Meningococcal septicemia ) A 393 MCC Chronic meningococcemia (Meningococcal septicemia ) A 400 MCC Sepsis due to streptococcus, group A A 401 MCC Sepsis due to streptococcus, group B A 403 MCC Sepsis due to Streptococcus pneumoniae A 409 MCC Streptococcal sepsis, unspecified A 4101 MCC Sepsis due to Methicillin susceptible Staphylococcus aureus A 4102 MCC Sepsis due to Methicillin resistant Staphylococcus aureus A 411 MCC Sepsis due to other specified staphylococcus A 412 MCC Sepsis due to unspecified staphylococcus A 413 MCC Sepsis due to Hemophilus influenzae A 414 MCC Sepsis due to anaerobes A 4150 MCC Gram-negative sepsis, unspecified A 4151 MCC Sepsis due to Escherichia coli [E. coli] 13

All Specifically Named Sepsis Infection Diagnoses are MCC’s I-10 code CC/MCC Code Description A 4152 MCC Sepsis due to Pseudomonas A 4153 MCC Sepsis due to Serratia A 4159 MCC Other Gram-negative sepsis A 4181 MCC Sepsis due to Enterococcus A 4189 MCC Other specified sepsis A 419 MCC Sepsis, unspecified organism A 5486 MCC Gonococcal sepsis B 007 MCC Disseminated herpesviral disease B 377 MCC Candidal sepsis R 571 MCC Hypovolemic shock R 578 MCC Other shock R 6510 CC Systemic inflammatory response syndrome (SIRS) of noninfectious origin without acute organ dysfunction MCC Systemic inflammatory response syndrome (SIRS) of noninfectious origin with acute organ dysfunction R 6520 MCC Severe sepsis without septic shock R 6521 MCC Severe sepsis with septic shock R 7881 CC R 6511 Bacteremia 14

Section I. Conventions, general coding guidelines and chapter specific guidelines CMS Official Coding and Reporting Guidelines 2020 A. Conventions for the ICD-10 -CM • I. A. 19. Code assignment and Clinical Criteria. • The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s *statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. * Sepsis Integrity Review Services 2019 15

Other Conditions Specific to Treatment Resistance I-10 Code CC/MCC Z 1610 None Resistance to unspecified beta lactam antibiotics Z 1611 None Resistance to penicillins Z 1612 None Z 1619 None Resistance to other specified beta lactam antibiotics Z 1620 None Resistance to unspecified antibiotic Z 1621 None Resistance to vancomycin Z 1622 None Resistance to vancomycin related antibiotics Z 1623 None Resistance to quinolones and fluoroquinolones Z 1624 None Resistance to multiple antibiotics Z 1629 None Resistance to other single specified antibiotic Z 1630 None Resistance to unspecified antimicrobial drugs Z 1631 None Resistance to antiparasitic drug(s) Z 1632 None Resistance to antifungal drug(s) Z 1633 None Resistance to antiviral drug(s) Z 16341 None Resistance to single antimycobacterial drug Z 16342 None Resistance to multiple antimycobacterial drugs Z 1635 None Resistance to multiple antimicrobial drugs Z 1639 None Resistance to other specified antimicrobial drug Code Description Extended spectrum beta lactamase (ESBL) resistance 16

Sepsis DRGs 870 = ONLY 1 Possible Procedure for this DRG 870 SEPTICEMIA OR SEVERE SEPSIS WITH Mechanical Ventilator > 96+ HOURS Any Sepsis Code ( See list of 43 Sepsis codes) + the PCS code for MECHANICAL VENTILATION 96+ HOURS 5 A 1955 Z Respiratory Ventilation, Greater than 96 Consecutive Hours Important note: Ventilator time < 96 Hours will Default to DRGs 871 - 872 (without ventilator > 96 hrs. ) 17

• When does the time counting start for ventilator time? https: //newsletters. ahima. org/newsletters/Co de_Write/2012/January/ventilator. html o CC 2014 4 th. Q Sepsis With Ventilator 870 • Can multiple episodes of ventilator time be added up to meet >96 hrs. total time? • CC 2014 4 th. Q • Is weaning time counted for Total Ventilator time? o CC 2014 4 th. Q 18

MS-DRG Ventilator Time Impact MS DRG- 870 SEPTICEMIA OR SEVERE SEPSIS WITH MV > 96+ HOURS MS DRG- 871 SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV> 96+ HOURS WITH MCC MS DRG- 872 SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV> 96+ HOURS WITHOUT MCC SIW- 6. 3243 Avg Reimb: $ 82, 791. 00 SIW- 1. 8663 Avg Reimb: $ 25, 195. 00 SIW- 1. 0393 Avg Reimb: $ 14, 030. 00 A 41. 50 Gram-negative sepsis, unspecified R 65. 21 (mcc) Severe sepsis with septic shock D 62 (cc) Acute Blood Loss Anemia Procedure 5 A 1955 Z Respiratory Ventilation, Greater than > 96 Consecutive Hours 5 A 1935 Z Respiratory Ventilation, less than < 24 Consecutive Hours 0 BH 17 EZ Insertion of Endotracheal Airway into Trachea, via natural or artificial opening 19

Sepsis Grouper Dashboard Compared MS-DRG V 37 870 Septicemia or Severe Sepsis With MV for 96+ Hours • SIW 6. 3243 • $82, 761. 00 APR-DRG V 34 (NYS) 720. 4 Septicemia and Disseminated Infections • SIW 3. 2003 • $43, 204. 00 • (Mech Vent time impacts the SOI) Sepsis Integrity Review Services 2019 APR-DRG V 37 (Other) 720. 4 Septicemia and Disseminated Infections • SIW 1. 7194 • $23, 211. 00 • (Mech Vent time impacts the SOI) 20

MDC 18 Infectious & Parasitic Diseases, Systemic or Unspecified Sites Infectious and Parasitic Diseases W/OR • DRG 853 INFECTIOUS AND PARASITIC DISEASES WITH O. R. PROCEDURE WITH MCC • DRG 854 INFECTIOUS AND PARASITIC DISEASES WITH O. R. PROCEDURE WITH CC • DRG 855 INFECTIOUS AND PARASITIC DISEASES WITH O. R. PROCEDURE WITHOUT CC/MCC 21

853 -855 DRGs PRINCIPAL DIAGNOSES from MDC 18 EXCEPT Any of these listed Diagnoses I-10 Code Description K 6811 Post procedural retroperitoneal abscess N 980 Infection associated with artificial insemination T 8022 XA Acute infection following transfusion, infusion, or injection of blood and blood products, initial encounter T 8029 XA Infection following other infusion, transfusion and therapeutic injection, initial encounter T 8140 XA Infection following a procedure, unspecified, initial encounter T 8141 XA Infection following a procedure, superficial incisional surgical site, initial encounter T 8142 XA Infection following a procedure, deep incisional surgical site, initial encounter T 8143 XA Infection following a procedure, organ and space surgical site, initial encounter T 8144 XA Sepsis following a procedure, initial encounter T 8149 XA Infection following a procedure, other surgical site, initial encounter T 880 XXA Infection following immunization, initial encounter And any valid OR procedure 22

(SEPSIS) Surgical/Significant Procedures for Acute Infectious and Parasitic Diseases MS-DRGs MS DRG- 853 INFECTIOUS AND PARASITIC DISEASES WITH O. R. PROCEDURE WITH MCC MS DRG- 854 INFECTIOUS AND PARASITIC DISEASES WITH O. R. PROCEDURE WITH CC MS DRG- 855 INFECTIOUS AND PARASITIC DISEASES WITH O. R. PROCEDURE W/O any CC/MCC SIW- 5. 0986 Avg Reimb: $68, 831. 00 SIW- 2. 1612 Avg Reimb: $29, 176. 00 SIW- 1. 6033 Avg Reimb: $21, 644. 00 A 41. 01 Sepsis due to Methicillin susceptible Staphylococcus aureus G 92 (mcc) Toxic Encephalopathy N 39. 0 (cc) Urinary tract infection unspecified D 64. 9 (non cc) Anemia, Unspecified Procedure 00 B 00 ZX Excision of brain, Open Approach, Diagnostic 00 B 00 ZX Procedure Excision of brain, Open Approach, Diagnostic 00 B 00 ZX Excision of brain, Open Approach, Diagnostic 23

(Non-Sepsis) Surgical/Significant Procedures for Acute Infectious and Parasitic Diseases MS-DRGs MS DRG- 853 INFECTIOUS AND PARASITIC DISEASES WITH O. R. PROCEDURE WITH MCC MS DRG- 854 INFECTIOUS AND PARASITIC DISEASES WITH O. R. PROCEDURE WITH CC MS DRG- 855 INFECTIOUS AND PARASITIC DISEASES WITH O. R. PROCEDURE WITHOUT CC/MCC SIW- 5. 0986 Avg Reimb: $68, 831. 00 SIW- 2. 1612 Avg Reimb: $29, 176. 00 SIW- 1. 6033 Avg Reimb: $21, 644. 00 A 17. 82 Tuberculous Meningoencephalitis G 93. 6 (mcc) Vasogenic Brain Edema N 39. 0 (cc) Urinary tract infection unspecified D 64. 9 (non cc) Anemia, Unspecified Procedure 00 B 00 ZX (OR proc) Excision of brain, Open Approach, Diagnostic 00 B 00 ZX (OR proc) Procedure Excision of brain, Open Approach, Diagnostic 00 B 00 ZX (OR proc) Excision of brain, Open Approach, Diagnostic 24

Most non communicable Infections will be found in the Appropriate Body System DRGs 1 st listed or Principal Diagnosis Infection of: Gastrointestinal Pulmonary Central Nervous System Skin/Soft tissue Bones Liver/Gallbladder/Pancreas Urinary Bladder/Kidneys Genitourinary Organ or Body system specific DRGS for localized infections , manifestations, and certain complications. These will sometimes require more than one I-10 code to fully report the infection. The DRG will be Validated Against Official Coding Guidelines, Excludes 1 notes, Excludes 2 notes, and pertinent Coding Clinic Guidelines for sequencing and etiology 25

Specific DRGs for Non-parasitic and Non. Infectious Other Body System Infections MS-DRG V 37 APR-DRG V 34 (NYS) APR-DRG V 37 (Other) MS DRG- 290 Acute and Subacute Endocarditis W/O CC or MCC APR- DRG- 193. 1 Acute and Subacute Endocarditis APR-DRG- 193. 1 Acute and Subacute Endocarditis SIW- 1. 0006 Avg Reimb: $ 13, 581. 00 SIW- 1. 0318 Avg Reimb: $ 13, 929. 00 SIW- . 6578 Avg Reimb: $ 8, 880. 00 I 33. 0 Acute and Subacute Infective Endocarditis Procedure none 3 E 03329 Introduce other anti-infective into peripheral vein, percutaneous approach 3 E 03329 Introduce other antiinfective into peripheral vein, percutaneous approach Non O. R. 26 Non O. R.

Post-operative and Post-traumatic Infections Sepsis Integrity Review Services 2019 27

Section I. Conventions, general coding guidelines and chapter specific guidelines CMS Official Coding and Reporting Guidelines 2020 B. 16 Documentation of Complications of care • I. B. 16 Code assignment and Clinical Criteria. Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. • The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented. Sepsis Integrity Review Services 2019 28

ICD-10 -CM Tabular Certain Infectious and Parasitic Diseases A 00 -B 99 Code details including- excludes notes, code also notes, code else where and code additional • Includes: Diseases generally recognized as Communicable and Transmissible • USE ADDITIONAL CODE: to identify resistance to antimicrobial drugs Z 16 - • Excludes 1: Certain localized infections – see body system related chapters These are specific types of infections usually involving a specific location or dissemination • Excludes 2: Infectious and parasitic diseases specific to the Perinatal Period P 35 -P 39, Carrier or suspected carrier of infectious disease Z 72. - Infectious and parasitic diseases complicating pregnancy, childbirth and the Puerperium O 98. - Influenza and other acute respiratory infections J 00 -J 22 • Code blocks for : Combination codes for etiology and location Some codes include the infection, location and the complication Intestinal Infectious diseases Tuberculosis Certain Zoonotic Bacterial Disease Other Bacterial Disease Infections with predominantly Sexual Mode of Transmission Other Spirochetal disease Other Diseases Caused by Chlamydiae Rickettsioses Viral and Prion Infections of the Central Nervous system Arthropod-Borne Viral Fevers and Viral Hemorrhagic Fevers Viral Infections Characterized by Skin and Mucous membrane lesions Other Human Herpes virus Viral Hepatitis Human Immunodeficiency Virus (HIV) disease Other Viral Diseases Mycoses Protozoal Diseases Helminthiases Pediculosis, Acariasis and other Infestations Sequela of infections and parasitic Diseases Bacterial and Infectious agents Other infectious disease 29

MDC 18 Infectious & Parasitic Diseases, Systemic or Unspecified Sites Post Operative & Post Traumatic Infections • DRG 862 POSTOPERATIVE AND POSTTRAUMATIC INFECTIONS WITH MCC • DRG 863 POSTOPERATIVE AND POSTTRAUMATIC INFECTIONS WITHOUT MCC 30

I-10 Code K 6811 T 8140 XA 862 -863 DRGs Using only these listed PRINCIPAL DIAGNOSES MDC 18 Description Post procedural retroperitoneal abscess Infection following a procedure, unspecified, initial encounter T 8141 XA Infection following a procedure, superficial incisional surgical site, initial encounter T 8142 XA Infection following a procedure, deep incisional surgical site, initial encounter T 8143 XA Infection following a procedure, organ and space surgical site, initial encounter T 8144 XA Sepsis following a procedure, initial encounter T 8149 XA Infection following a procedure, other surgical site, initial encounter 31

Section II. Selection of Principal Diagnosis CMS Official Coding and Reporting Guidelines 2020 G. Complications of Surgery and Other Medical Care • II. G. When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T 80 -T 88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned. Sepsis Integrity Review Services 2019 32

Post-Operative and Post-Traumatic Infections MS DRG- 862 POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC MS DRG- 863 POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC SIW- 1. 8506 Avg Reimb: 24, 983. 00 T 8144 XA Sepsis following a procedure, initial encounter SIW-. 9880 Avg Reimb: $13, 388. 00 T 8144 XA Sepsis following a procedure, initial encounter A 419 (mcc) Sepsis unspecified N 39. 0 (cc) Unspecified Urinary tract infection Procedure none 33

Grouper Dashboard Compared MS-DRG V 37 862 Post Operative & Posttraumatic Infections With MCC • SIW 1. 8506 • $24, 983. 00 APR-DRG V 34 (NYS) APR-DRG V 37 (Other) 721. 4 Post-operative, Posttraumatic, other device infections Septicemia and Disseminated Infections • SIW 3. 2003 • $43, 204. 00 • SIW 1. 7194 • $23, 211. 00 Sepsis Integrity Review Services 2019 34

4 DRGs Assigned For APR DRGS Sepsis, Infectious & Parasitic Diseases, HIV, Post-operative, Post-traumatic Infections and Procedures • Surgical DRGs 2 Blocks Infections and Parasitic Diseases with HIV and O. R Procedure 710 Postoperative or Post-Traumatic Infections with Procedure 711 • Medical DRGs 2 Blocks Septicemia and Disseminated Infections 720 Post-Operative, Post-Traumatic & Other Device Infections 721 35

APR-DRGs 710 -711 720 -721 SOI 1 -4 Sepsis Integrity Review Services 2019 36

Section I. Conventions, general coding guidelines and chapter specific guidelines CMS Official Coding and Reporting Guidelines 2020 C. 1. Chapter specific coding Chapter 1: Certain Infectious and Parasitic Diseases (A 00 -B 99) 5) Sepsis due to a postprocedural infection For infections following a procedure, a code from T 81. 40, to T 81. 43 Infection following a procedure is assigned • I. C. 1. d. 5). (c) Postprocedural infection and postprocedural septic shock • If a postprocedural infection has resulted in postprocedural septic shock, assign the codes indicated T 81. 40, to T 81. 43 for sepsis due to a postprocedural infection, followed by code T 81. 12 -, Postprocedural septic shock. Do not assign code R 65. 21, Severe sepsis with septic shock. Additional code(s) should be assigned for any acute organ dysfunction Sepsis Integrity Review Services 2019 37

MDC 18 Infectious & Parasitic Diseases, Systemic or Unspecified Sites Post Procedural Infections • DRG 856 POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O. R. PROCEDURE WITH MCC • DRG 857 POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O. R. PROCEDURE WITH CC • DRG 858 POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O. R. PROCEDURE WITHOUT CC/MCC 38

856 -858 DRGs using only these 11 listed PRINCIPAL DIAGNOSES I-10 Code Description K 6811 Post procedural retroperitoneal abscess N 980 Infection associated with artificial insemination T 8022 XA Acute infection following transfusion, infusion, or injection of blood and blood products, initial encounter T 8029 XA Infection following other infusion, transfusion and therapeutic injection, initial encounter T 8140 XA Infection following a procedure, unspecified, initial encounter T 8141 XA Infection following a procedure, superficial incisional surgical site, initial encounter T 8142 XA Infection following a procedure, deep incisional surgical site, initial encounter T 8143 XA Infection following a procedure, organ and space surgical site, initial encounter T 8144 XA Sepsis following a procedure, initial encounter T 8149 XA Infection following a procedure, other surgical site, initial encounter T 880 XXA Infection following immunization, initial encounter And any valid OR procedure 39

Post-Operative and Post-Traumatic Infections With an Operative Procedure MS DRG-856 POSTOPERATIVE OR POSTTRAUMATIC INFECTIONS WITH O. R. PROCEDURE WITH MCC MS DRG-857 POSTOPERATIVE OR POSTTRAUMATIC INFECTIONS WITH O. R. PROCEDURE WITH CC MS DRG-858 POSTOPERATIVE OR POSTTRAUMATIC INFECTIONS WITH O. R. PROCEDURE WITHOUT CC/MCC SIW- 4. 4257 Avg Reimb: $59, 746. 00 SIW- 2. 0333 Avg Reimb: $27, 499. 00 SIW- 1. 3764 Avg Reimb: $ 18, 581. 00 T 81. 41 XA Infection following a procedure, superficial incisional surgical site, initial encounter L 89. 154 (mcc) Pressure ulcer of sacrum Stage 4 I 82. 621 (cc) Acute Embolism and thrombosis of deep veins rt lower ext (cc) Z 66 (no mcc/cc) Do Not Rescue Procedure 0 QB 10 ZX Procedure Excision of Sacrum, open approach diagnostic 0 JD 90 ZZ Extraction of buttock, subq, tissue & Fascia, open approach 0 JD 90 ZZ Extraction of buttock, subq, tissue & Fascia, open approach 40

Grouper Dashboard Compared APR-DRG V 34 (NYS) APR-DRG V 37 (Other) 856 Post-op or posttraumatic infections with O. R. Procedure with mcc 711. 4 Post-op, Posttraumatic, Other device Infections With O. R. procedure • SIW 6. 3243 • $82, 761. 00 • SIW 2. 8749 • $30, 342. 00 711. 4 Post-op, Posttraumatic, Other device Infections With O. R. procedure • SIW 3. 9201 • $35, 157. 000 MS-DRG V 37 Sepsis Integrity Review Services 2019 41

Sequencing guidelines for post procedure Sepsis due to complications from Devices in Body Systems, Systems May Generate DRGs in other MDCs MDC 18 DRGs 853 -872 • Sepsis, SIRS, Septic Shock, Bacteremia • Post Operative and Post Traumatic Infections • O. R. Procedures for Sepsis, Infectious and parasitic Diseases May be in any other MDCs & Body System DRGs Gastrointestinal Pulmonary Cardiovascular Central Nervous System Skin/Soft tissue/Muscle Musculoskeletal/Bones Liver/Gallbladder/Pancreas Urinary Bladder/Kidneys Genitourinary OB/Newborn 42

MS-DRGs Other Infections That are Due to Complication of the DEVICE MS DRG- 559 Aftercare, Musculoskeletal System and Connective Tissue with MCC MS DRG- 698 Other Urinary Tract Diagnoses with MCC MS DRG- 919 Complications of Treatment With MCC SIW- 1. 8018 Avg Reimb: $24, 324. 00 SIW- 1. 6186 Avg Reimb: $21, 851. 00 SIW- 1. 8253 Avg Reimb: $24, 641. 00 T 84. 52 XA Infection and inflammatory reaction due to internal left hip prosthesis, Initial Encounter T 83. 518 A Infection and inflammatory reaction due to other urinary catheter, initial encounter T 86822 Skin graft (allograft) (autograft) infection L 89. 154 (mcc) Pressure ulcer of sacrum Stage 4 G 92 (mcc) Toxic Encephalopathy L 89. 154 (mcc) Pressure ulcer of sacrum Stage 4 (mcc) Procedure none 43

APR- DRGs Other Infections That are Due to Complication of the DEVICE APR-DRG 349. 3 Malfunction, reaction, complication of Orthopedic Device or procedure APR-DRG 466. 3 Malfunction, reaction, complication of APR-DRG 813. 2 Other complications of Treatment SIW- . 8537 Avg Reimb: $11, 524. 00 SIW- . 7953 Avg Reimb: $10, 736. 00 SIW-. 5673 Avg Reimb: $7, 658. 00 T 84. 52 XA Infection and inflammatory reaction due to internal left hip prosthesis, Initial Encounter T 83. 518 A Infection and inflammatory reaction due to other urinary catheter, initial encounter T 86822 Skin graft (allograft) (autograft) infection L 89. 154 (mcc) Pressure ulcer of sacrum Stage 4 G 92 (mcc) Toxic Encephalopathy L 89. 154 (mcc) Pressure ulcer of sacrum Stage 4 Procedure none Genitourinary Device or procedure 44

APR-DRG Severity Factors for Sepsis DRGs • Personal History of Heart assist device (CC) • Need for Isolation • Personal History of fully implantable artificial heart (CC) • Renal Dialysis status • Hx of lung transplant (CC) • Personal History allergy antinfective • Hx Kidney Transplant (CC) • Personal History of DVT/CVA • Hx Heart Transplant (CC) • Personal History Pulmonary embolism • Dependence on O 2 (oxygen) • Hypotension • Ventilator Dependant (CC) • Tachycardia • Personal Trach status • Failure to Thrive • Personal history of Cardiac Arrest • Under nourished/cachectic • Personal History of MI • Morbid Obesity • Personal Hx Heart Valve Replacement • Hyperkalemia • Personal hx of surgery of heart and great vessels • Hypo/hypercalcemia • Personal Hx of CABG • Hypo/hypermagnesemia • Personal Hx of PTCA/AICD/Pacemaker • Uncontrolled Type II Diabetes • Waiting on transplant list • Vitamin B 12 and Vitamin D deficiency • Respiratory abnormality • Calcium deficiency nutritional • Change of mental status • Personal History of Non-compliance • Personal hx Drug resistant infection • Long term current use of steroids • Personal Hx MRSA • Long term use of anticoagulants • Mechanical Ventilator time > 96 hours (SOI 3) • Chemotherapy and Radiation personal hx status 45

DRG Impacted by Root Operation and the Approach Taken for PCS Body System Root Operation Body Part Approach Other Qualifiers Device 46

Root Operation, Approach, Qualifier and the DRG Impact Excision • 0 HB 8 XZZ- Excision of Buttock Skin, External Approach (MS-DRG 872) (APR-DRG 720) Non- O. R. • 0 JB 90 ZX- Excision of Buttock Sub-q Tissue & Fascia, Open Approach, Diagnostic (MS-DRG 872) (APR-DRG 720) Non- O. R. • 0 JB 90 ZZ –Excision of Buttock Sub-q Tissue & Fascia, Open approach, Not Diagnostic (MS-DRG 855) Sepsis with an O. R. (APR-DRG 720) Sepsis without an O. R. Extraction • 0 HD 8 XZZ- Extraction of Buttock Skin, External Approach (MS-DRG 872) (APRDRG 720) Non- O. R. • 0 JD 90 ZZ- Extraction of Buttock Sub-q tissue & Fascia, Open approach (extraction has no qualifier) (MS-DRG 855) (APR-DRG 710) Both DRGs are Sepsis with an O. R. • Examples of extraction- pulse jet, scrubbing/scraping, etc. Sepsis Integrity Review Services 2019 47

CMS Official Coding and Reporting Guidelines 2020 Biopsy followed by more definitive treatment B 3. 4 b If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure, such as Destruction, Excision or Resection at the same procedure site, both the biopsy and the more definitive treatment are coded. Example: Biopsy of breast followed by partial mastectomy at the same procedure site, both the biopsy and the partial mastectomy procedure are coded. Sepsis Integrity Review Services 2019 48

Root Operation, Approach, Device and the DRG Impact Revision Bypass (redo of prior trach site) • 0 BW 10 FZ – Revision of Tracheostomy Device in Trachea, Open Approach (MS-DRG 855) (APR-DRG 710) (both DRGs are Sepsis with O. R. ) • Revision can only be used when there is a device in the neck (trach in situ) and that same device remains but needs correcting to the extent possible, a portion of the malfunctioning device or the position of the displaced device. • – if the tube is removed and new tube inserted the root operation would be “change” • 0 B 110 F 4 - Bypass Trachea to Cutaneous with Tracheostomy Device, Open Approach (MS-DRG 004 Trach) (APR-DRG 710 * No Trach) • MS-DRG will Generate the trach DRG regardless of the presence of the code for ventilator or the time on the Ventilator • * the only way to generate the APR-DRG for Trach (005) is to have an additional code of 5 A 1955 Z- Respiratory Ventilation, Greater than >96 consecutive hours, and the trach bypass code • The trach APR-DRG, when vent hours < 96, no Trach DRG assigned and the case will default to the 710 O. R. sepsis DRG. Sepsis Integrity Review Services 2019 49

Root Operation, Approach, Body Part and the DRG Impact Drainage Extirpation • 0 B 9 F 8 ZZ- Drainage of RLLL, Via natural or Artificial Opening Endoscopic (not diagnostic) (MS-DRG 871) Non- O. R. (APR- DRG 720) • 0 BCF 8 ZZ – Extirpation of Matter from RLLL, Via Natural or Artificial Opening Endoscopic (MS-DRG 853) (APR-DRG 710) (both DRGs Sepsis with O. R. procedure) • 0 B 9 F 8 ZX- Drainage RLLL, Via Natural or Artificial Opening, Endoscopic, Diagnostic (MS -DRG 871) Non- O. R. (APR-DRG 720) Sepsis Integrity Review Services 2019 50

AHA Coding Clinic Advice 3 rd Q 2017 Question: A bronchoscopy was performed due to abnormal radiologic findings in the lung field. The right middle lobe bronchus was occluded by a large mucus plug. Mucomyst was administered locally and the mucus plug washed and suctioned. Bronchial washings were submitted for microbiology. What is the correct code assignment for washing/lavage with suction of mucus plug? Sepsis Integrity Review Services 2019 Answer: This procedure meets the definition of the root operation "Extirpation" - taking or cutting out solid matter from a body part. Assign the following ICD- 10 -PCS code: 0 BC 58 ZZ Extirpation of matter from right middle lobe bronchus, via natural or artificial opening endoscopic, for suctioning of the mucus plug The suctioning (extirpation) is the definitive procedure, and it is not required to code separately the irrigation (washing). 51

Monitor, Trend and Review your Hospital Data for Accuracy. Know your hospital PSI score and Benchmark for Sepsis Key Take Away Points Establish standards for sepsis diagnosis criteria, documentation, and terminology used by providers in the EMR Use external denials to help you evaluate Sepsis Documentation/Coding. Educate coders, CDI and providers with focus on the gaps Identified Query and confirm post-operative/procedural, and post traumatic sepsis for Accurate Code Assignment Scrutinize operative reports and informed consent for the surgical Objectives for the procedures performed Sepsis Integrity Review Services 2019 52

References and Resources • www. Sepsis. Integrity. Review. Services. Com • https: //www. cms. gov/icd 10 m/version 37 -fullcodecms/fullcode_cms/P 0001. html • https: //www. health. ny. gov/facilities/hospital/reimbursement/aprdrg/weights/2018 -07 -01_final_weights. htm • https: //ny. sepsis. ipro. org/files/documents/adult/6 -3/dictionary. pdf Sepsis Integrity Review Services 2019 53

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