ICD-10-CM: Sepsis

Tropin’s Medical Coding Made Easy

7 Jan 202124:37

EducationalLearning

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TLDRIn this detailed and informative lesson, Terri Tropin, an AHIMA approved ICD-10 trainer with over 20 years of teaching experience, delves into the complexities of ICD-10-CM coding for sepsis. Terri begins by introducing herself, highlighting her extensive background in health information technology and authorship of several coding study guides. The lesson methodically breaks down the definitions, coding guidelines, and distinctions between sepsis, severe sepsis, septic shock, and Systemic Inflammatory Response Syndrome (SIRS), emphasizing the importance of accurate documentation and coding for healthcare administration. Through practical examples and a systematic approach, Terri equips viewers with the knowledge to navigate the nuances of coding for sepsis and its related conditions, reinforcing learning with practice scenarios and expert tips for utilizing the ICD-10-CM manual effectively.

Takeaways

📖 Terri Tropin introduces herself as a healthcare administration and informatics expert with over 20 years of teaching experience at Montgomery College, highlighting her credentials in RHIA and CCS certification, and authorship of coding study guides.
📌 Defines sepsis as a systemic infection affecting multiple body systems, distinguishing between bacteremia, septicemia (coded as sepsis), severe sepsis (including acute organ dysfunction), and septic shock (circulatory failure associated with severe sepsis).
🛠 Emphasizes the importance of physician documentation for accurate sepsis coding, noting that even without positive blood cultures, documented sepsis can still be coded as such.
🔹 Differentiates between sepsis and severe sepsis coding guidelines, specifying that severe sepsis requires at least two codes: one for the underlying infection and another for associated acute organ dysfunction.
📝 Highlights that codes from R65 (indicating severe sepsis or SIRS) should never be used as a principal diagnosis and that severe sepsis coding requires specific sequences depending on the timing and nature of the infection and organ dysfunction.
📚 Provides practice scenarios for coding sepsis, severe sepsis, and SIRS, demonstrating how to select and sequence codes based on different patient conditions and documentation.
🖊 Discusses the coding of SIRS (Systemic Inflammatory Response Syndrome) and its dependence on whether it's related to an infectious or non-infectious process, with specific coding instructions for each scenario.
👥 Stresses the necessity of clear documentation linking sepsis or severe sepsis to procedural complications for accurate coding, including the use of specific codes for post-procedural infections.
📈 Offers detailed advice on how to annotate and use the ICD-10-CM manual effectively for coding sepsis, severe sepsis, and related conditions, suggesting specific notes to make in the coding book for quick reference.
💎 Encourages engagement and feedback through her social media and contact details, and promotes her coding books available on Amazon for further learning and reference.

Q & A

What is Terri Tropin's educational background?
-Terri Tropin has a master's degree in healthcare administration informatics from the University of Maryland Global Campus.
What certifications does Terri Tropin hold?
-Terri Tropin holds RHIA and CCSP certifications and is an AHIMA-approved ICD-10 trainer.
What is the difference between sepsis and severe sepsis as explained in the lesson?
-Sepsis is defined as a systemic infection including organisms in the bloodstream. Severe sepsis goes a step further to include acute organ dysfunction.
Can sepsis be coded if the blood culture results are negative or inconclusive?
-Yes, sepsis can still be coded as such if the physician confirms it, regardless of negative or inconclusive blood culture results.
What should not be used as a principal diagnosis according to the guidelines presented?
-Codes from subcategory R65, which relates to symptoms and signs, should never be used as a principal diagnosis.
How is septic shock defined and coded?
-Septic shock is defined as a circulatory failure associated with severe sepsis and is always coded as severe sepsis.
What is the protocol for coding severe sepsis that develops after hospital admission?
-If severe sepsis develops after admission, list the other reason the patient was admitted first, then code the underlying systemic infection and R65.2 for severe sepsis, followed by any organ dysfunction if documented.
What are Terri Tropin's contributions to ICD-10-CM coding literature?
-Terri Tropin has written several books on coding, including study guides that summarize coding guidelines for EM coding, ICD-10-CM, PCS, and external cause coding, available on Amazon.
What must be clearly associated with the sepsis to code it as severe sepsis?
-The acute organ dysfunction must be clearly associated with the sepsis to code it as severe sepsis.
What is the proper coding sequence for a patient admitted with severe sepsis?
-For a patient admitted with severe sepsis, code the underlying systemic infection first, followed by R65.2 for severe sepsis, then any associated organ dysfunction codes.

Outlines

00:00

📚 Introduction to ICD-10-CM Coding for Sepsis

Terri Tropin, an experienced health information technology educator with a Master's in Healthcare Administration Informatics, introduces ICD-10-CM coding for sepsis. She outlines her credentials, including RHIA and CCS-P certifications, and her role as an AHIMA-approved ICD-10 trainer. Terri has authored several coding study guides available on Amazon. She defines sepsis as a systemic infection and differentiates it from severe sepsis and septic shock, emphasizing the importance of accurate documentation and coding according to the ICD-10-CM guidelines.

05:05

📖 Detailed Coding Guidelines for Sepsis and Severe Sepsis

Terri elaborates on the coding process for sepsis and severe sepsis, stressing the need for precise documentation. She explains how sepsis is coded based on physician documentation and lab results, with severe sepsis requiring additional coding for acute organ dysfunction. The sequence of coding is crucial, especially when severe sepsis is present at admission, affecting the coding priority. Terri also addresses the coding nuances when sepsis develops after admission and the necessity of documenting the connection between sepsis and any procedural operations.

10:06

🔍 Practice Examples and Coding SIRS

Terri provides practice examples to demonstrate coding for sepsis and severe sepsis, including cases with septic shock and organ failure. She explains the coding for Systemic Inflammatory Response Syndrome (SIRS), distinguishing between infectious and non-infectious origins, and how this affects the coding process. Through these examples, she illustrates the importance of sequencing codes correctly and the impact of the patient’s condition on the coding strategy.

15:07

📈 Advanced Coding Scenarios for Post-Procedural Sepsis

Terri discusses advanced coding scenarios, focusing on post-procedural sepsis and septic shock. She emphasizes the importance of documentation showing the causality between the procedure and the septic condition for accurate coding. The segment covers the specifics of coding for post-procedural infections, including the depth of infection, the site, and related organ dysfunction, outlining the need for multiple codes to fully represent the clinical picture.

20:07

📝 Effective Coding Practices and Resource Utilization

Terri concludes with advice on effective coding practices, stressing the importance of note-taking and proper documentation within the ICD-10-CM manual to aid recall and accuracy. She offers suggestions on marking important coding guidelines in the manual and encourages the use of her study guides for further learning. Terri also invites interaction through her Facebook page and email, highlighting her commitment to education and ongoing learning in medical coding.

Mindmap

Keywords

💡ICD-10-CM

ICD-10-CM stands for the International Classification of Diseases, Tenth Revision, Clinical Modification. It's a coding system used by healthcare professionals to classify and code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care in the United States. In the video, Terri Tropin discusses how to correctly apply ICD-10-CM coding for sepsis, emphasizing the importance of accurate coding in healthcare documentation and billing.

💡Sepsis

Sepsis is described in the video as a systemic infection that affects multiple body systems, potentially including organisms in the bloodstream like bacteremia and septicemia. The correct coding of sepsis in ICD-10-CM is crucial for treatment, billing, and statistical purposes. Sepsis can lead to severe sepsis when it causes acute organ dysfunction, illustrating the severity and potential complications associated with the condition.

💡Severe Sepsis

Severe sepsis is defined as a systemic infection that progresses to include acute organ dysfunction. The video highlights the differentiation between sepsis and severe sepsis, noting the latter's greater complexity and the need for specific coding practices in ICD-10-CM to reflect the severity of the patient's condition accurately.

💡Septic Shock

Septic shock is identified as a circulatory failure associated with severe sepsis, marking a critical condition that requires immediate medical attention. The video underscores the necessity of correctly coding septic shock in ICD-10-CM, given its life-threatening nature and the implications for treatment and healthcare resources.

💡Coding Guidelines

The video provides detailed explanations of the coding guidelines for sepsis, severe sepsis, and septic shock within the ICD-10-CM framework. These guidelines help ensure that healthcare providers and coders accurately document patients' conditions, which is essential for treatment, billing, and compiling health statistics.

💡Organ Dysfunction

Organ dysfunction is a critical concept in distinguishing between sepsis and severe sepsis. The video clarifies that severe sepsis involves the presence of acute organ dysfunction, and it provides guidance on how to document and code this condition accurately in ICD-10-CM, stressing the significance of linking the organ dysfunction directly to the sepsis.

💡R65 Codes

R65 codes in ICD-10-CM are specifically used for coding severe sepsis and systemic inflammatory response syndrome (SIRS). The video emphasizes that R65 codes should never be used as principal diagnoses and outlines the conditions under which they can be appropriately applied, illustrating the nuances of coding practices for complex conditions.

💡Systemic Inflammatory Response Syndrome (SIRS)

SIRS is mentioned as a condition that may result from an infectious or non-infectious process, such as a burn or trauma. The video discusses how to code for SIRS in ICD-10-CM, depending on its cause, and the importance of distinguishing between infectious and non-infectious origins for accurate documentation.

💡Localized Infection

The video addresses scenarios where a patient may be admitted with a localized infection that later develops into sepsis or severe sepsis. It provides insight into how to code these conditions correctly in ICD-10-CM, illustrating the progression of an infection from localized to systemic and the implications for coding and treatment.

💡Post-procedural Sepsis

Post-procedural sepsis is discussed as a condition that can occur following a medical procedure. The video outlines the specific ICD-10-CM coding guidelines for such cases, including the need to document a direct link between the procedure and the sepsis. This section highlights the challenges of coding for complications that arise after medical interventions.

Highlights

Terri Tropin introduces herself as an experienced ICD-10 trainer with over 20 years of teaching at Montgomery College and author of coding study guides.

Definition of sepsis as a systemic infection, with distinctions between bacteremia, septicemia, severe sepsis, and septic shock.

Explanation of non-infectious processes leading to sepsis, including burns and injuries.

Guidelines for coding sepsis when blood culture results are negative or inconclusive, emphasizing physician's diagnosis.

Criteria for coding acute organ dysfunction as severe sepsis.

Instruction on using specific codes for sepsis and severe sepsis based on ICD-10-CM guidelines.

Explanation of the importance of coding the underlying cause of sepsis first, followed by codes for severe sepsis and associated organ dysfunction.

Details on the sequencing of codes when severe sepsis is present upon hospital admission versus developing after admission.

Guidance on coding septic shock always as severe sepsis and the ordering of codes according to the underlying systemic infection.

Summarization of key points for coding sepsis, severe sepsis, and SIRS, including when to use R65 codes.

Practice exercises to apply coding knowledge on sepsis, severe sepsis, and related conditions with ICD-10-CM codes.

Explanation of coding SIRS based on whether it's due to an infectious or non-infectious condition.

Guidelines for coding post-procedural sepsis, including the necessity of documenting the relation to the procedure.

Steps for coding infections following infusions, injections, and transfusions as complications of procedures.

Tips for effectively utilizing the ICD-10-CM manual, including annotating it with notes to aid in quick reference and accurate coding.

Terri Tropin encourages feedback and interaction through social media and email, highlighting the supportive community for learners.

Transcripts

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Related Tags

ICD-10-CM Healthcare Coding Sepsis Coding Medical Education Health Informatics Terri Tropin Coding Guidelines Professional Certification Health Administration Medical Books