I am attaching you a coding alert article regarding sepsis/sirs which will clear your doubts.
Sepsis is one of the most commonly miscoded conditions in the inpatient setting. And if you're unfamiliar with its exact pathology, you can easily misinterpret documentation - which may not be crystal-clear in the first place. Follow these expert hints to spot giveaway terms and symptoms.
The mistake coders most often make is mistaking "sepsis" and "SIRS" (systemic inflammatory response syndrome) with infection, when both conditions are actually responses to infection, says James Kennedy, MD, CCS, vice president of MA Health Solutions Inc. in Nashville, Tenn. A patient cannot develop sepsis without first experiencing SIRS.
Understand SIRS to Understand Sepsis
SIRS may result from a number of causes, including pancreatitis, burns, trauma, or infection, among others - so you should keep in mind that "SIRS doesn't necessarily mean the patient has an infection," Kennedy says. "I talk to coders all the time who see the elevated white count, the elevated temperature," which are symptoms of SIRS, "and they go, 'Oh, there must be an infection.' But other things can cause this - I can have an infection and not have SIRS." In order to develop sepsis, though, the SIRS must be due to infection.
One common symptom of SIRS is multiorgan dysfunction, a condition in which the patient's organs are temporarily stunned. The patient may then suffer from ailments such as low blood pressure, low platelet count, in-creased heart rate, confusion or psychosis, jaundice, and gastrointestinal bleeding. Keep your eyes peeled for these common phrases physicians use to define multiorgan dysfunction: metabolic acidosis, shock (low systolic blood pressure for over an hour), septic encephalopathy, and liver failure. Of course, Kennedy says, "Unless your doctor documents this, you can't code it." But knowing these giveaway terms, he says, "helps you decide when to query the physician."
Sepsis, by definition, is the systemic inflammatory response to infection manifested by certain SIRS conditions. Essentially, if the patient has an infection and develops SIRS, the intersection of these conditions is sepsis.
Determine Severity for Correct SIRS Code
Depending on the intensity of the patient's SIRS, the presence or absence of organ failure, and whether the inflammatory response is due to infection, you will choose one of the following codes:
995.90 - SIRS, unspecified
995.91 - SIRS due to infectious process without organ dysfunction
995.92 - ... with organ dysfunction
995.93 - SIRS due to non-infectious process without organ dysfunction
995.94 - ... with organ dysfunction.
You should note that code 995.91 is the same as sepsis, Kennedy says. For 995.92, however, you must see the phrase "severe sepsis" to report it - even if you know the patient's condition by looking at the chart - so make sure your physicians know they need to write those specific words. When reporting codes that describe SIRS with organ failure (995.92 and 995.94), be sure to report the code for the dysfunction and underlying condition in addition to the SIRS code.
For example, suppose the documentation states that the patient has sepsis from a viral infection and has organ failure because of it. In this case, you would first report the underlying condition - the infection itself - with 079.99 (Unspecified viral infection). Then you would report the sepsis with 995.92, as long as the doctor has stated "severe sepsis." Finally, you would code for the symptoms of the organ dysfunction. For instance, if the patient had respiratory failure, renal failure, and gastrointestinal failure, you may report 518.81 (Acute respiratory failure), 584.5 (Acute renal failure; with lesion of tubular necrosis), and 535.1x (Atrophic gastritis), depending on the nature of the dysfunction.
Locate Sepsis on the Disease Continuum
In order to filter through physician documentation on a sepsis patient, you'll need to know the possible degrees of inflammatory response. For example, a patient has an infection that results in SIRS, which means he has sepsis, during which he may have hypotension and other symptoms. The sepsis goes uncontrolled and turns into severe sepsis, and the patient's organs fail. If the severe sepsis advances, the patient has septic shock, a condition in which his low blood pressure is unresponsive to fluid resuscitation and his organs don't respond to treatment.
Don't Be Fooled by Adjectives
Instead of describing a patient's condition with the term SIRS, the physician may say the patient has a certain type of sepsis by associating the condition with an organism, an anatomic area, or a clinical circumstance. For example, you may need to code conditions such as "pneumococcal sepsis," "urinary sepsis," or "puerperal sepsis."
For sepsis described by an organism, such as Gram-negative or pneumococcal, you should report the SIRS code (995.91) instead of 038.9 (Unspecified septicemia) as well as the underlying cause of infection, Kennedy says. If the descriptor is an anatomic area or clinical circumstance, you won't use a SIRS code at all, but a code specific to the infection of that location or circumstance. For urinary sepsis, for instance, you'd report 599.0 (Other disorders of urethra and urinary tract; urinary tract infection, site not specified) and add the septicemia code 038.9.