# Presentation: 882402

## ICD-9-CM Coordination and Maintenance Committee MeetingNovember 2nd, 2001

- Peter Morris, MD, FACP, FCCP
- Wake Forest University School of Medicine

## Overview

- Definitions of Septicemia, Sepsis, 	& Severe Sepsis
- Disease Epidemiology
- Current Diagnostic codes
- Proposed Changes
- Discussion

## Definitions

- Septicemia 							Presence of microrganisms or their toxins          		in the blood
- Sepsis 								Systemic inflammatory response to infection.                                                             	The clinical manifestation of sepsis is the                                       	_*Systemic Inflammatory Response Syndrome *_

- Bone et.al., Chest  1992; 101: 1644-1653

## Definitions Continued

- SIRS the systemic inflammatory response to a variety of severe clinical insults
-  Two or more of the following:
- Temperature >38 C or <36 C
- Heart Rate > 90 beats per minute
- Respiratory Rate > 20 breaths per minute or PaCO2 < 32 mm Hg
- White Blood Cell Count > 12,000/cu mm, <4,000/cu mm or >10% immature (band) forms

- Bone, Roger et.al., Chest , Volume 101, No 6, June 1992 pages 1644-1653

## SIRS / Sepsis

**SIRS / Sepsis**

## Sepsis: Defining a Disease Continuum

- Sepsis: Defining a Disease Continuum

***SIRS***
- Temperature 38oC or 36oC
- HR 90 beats/min
- Respirations 20/min
- WBC count 12,000/mm3 or 4,000/mm3 or >10% immature neutrophils

- Sepsis

- Infection

**Severe Sepsis**

- Sepsis with  1 sign of organ failure
- Cardiovascular (refractory hypotension)
- Renal
- Respiratory
- Hepatic
- Hematologic
- CNS
- Unexplained metabolic acidosis

**Mechanical Ventilation**

**Acute Dialysis**

**Notes:**
Most normal cells have two copies of the HER2 gene and small amounts of HER2 protein on their surfaces (Hynes and Stern, 1994).
For reasons not currently known, cells may produce many copies of the HER2 receptor, a condition known as overexpression.
HER2 protein overexpression is associated with increased cell division and a high rate of tumor growth. It may also be associated with transformation to the cancer cell phenotype (Kraus et al, 1987; DiFiore et al, 1987; Hudziak et al, 1987).
HER2 protein overexpression has been reported in malignancies other than breast cancer, including
ovarian cancer (Slamon et al, 1989)
gastric cancer (Yonemura et al, 1991)
colon cancer (Holzmann et al, 1992)
endometrial cancer (Hetzel et al, 1992; Saffari et al, 1995)
lung cancer (Kern et al, 1993; Pastorino et al, 1993)
salivary gland cancer (Press et al, 1994) 
pancreatic cancer (Peiper et al, 1997) 
prostate cancer (Ross et al, 1997; Zhang et al, 1998)
The significance of HER2 protein overexpression in these cancers is not yet known.

## Definitions Continued

- Severe Sepsis: Sepsis associated with organ dysfunction (failure)
**Organ dysfunction (failure) may be cardiovascular, renal, respiratory, hepatic, hematological, central nervous system or unexplained metabolic acidosis.**

## Risk Assessment Based on “Sepsis” Definition Subsets

- Risk Assessment Based on “Sepsis” Definition Subsets

- 3709 patients followed
- 2527 met SIRS
- 649 (26%) developed SEPSIS
- 577 (22%) developed SEVERE SEPSIS

## Sepsis

- No SIRS

- SIRS2

- SIRS3

- SIRS4

- SevereSepsis

- With Shock

## Severe Sepsis Incidence

- 751,000 cases occur in the US annually		Median age:                                                         		63 (teaching hospitals)           			72 (non-teaching hospitals)	              			(Crit Care Med, July ‘01, Vol. 29, 1303-10)
- If Severe Sepsis Develops –                  		1 out of every 2-3 Patients Die
- 			(Mortality Rate 30% to 50%)

## Differences between           Severe Sepsis and Septicemia

## Existing Codes:Confusion exists for categorizing Severe Sepsis patients

- Severe sepsis coded under 38.9 is inappropriate
- Only 30% of cases with severe sepsis had (038) code listed.
- Incidence of severe sepsis underestimated

- Linde-Zwrible et.al, Value in Health, volume 4, number 2, March/April 2001, page 61.

## Current Coding

- Septicemia NOS, and Sepsis NOS coded to 038.9
- Does not include entire pathogenic microorganisms or their toxins in the blood.

## All Hospital

**All Hospital**

** ****In-Patients**

**ICU Patients**

**Mechanically**

**Ventilated **

**Patients**

**Severe Sepsis**

- Septicemia

## Suggested Coding

- New Code		**995  **                                          	Certain adverse events not elsewhere classified
- New Subcategory	**995.9** SIRS
- New Code		**995.91** SIRS _***w/o***_ organ failure
- New Code		**995.92** SIRS _***with***_ organ failure

*Add Severe Sepsis*
*Add Use additional code to specify organ failure*