# Presentation: 049868

## ICD-9-CM Coordination and Maintenance Committee MeetingDecember 6th, 2002

- Howard Levy, MD, PhD, MMM

- Promoting Clear Identification of Sepsis, Severe Sepsis & Septic Shock

## Overview

- Differentiation between Septic Shock in relation to other conditions in current code, Sepsis, and Severe Sepsis
- Disease Epidemiology, Incidence and Mortality
- Inadequacy of Current Diagnostic Codes
- Proposed Modifications and Clarification
- Discussion

## Sepsis: Defining a Disease Continuum

**   ****A clinical response arising from a nonspecific insult, including ******** ****2 of the following:**
**Temperature ********38****o****C or ********36****o****C**
**HR ********90 beats/min**
**Respirations ********20/min**
**WBC count ********12,000/mm****3**** or**** ********4,000/mm****3**** or >10% immature neutrophils**

**SIRS = Systemic Inflammatory Response Syndrome**

**SIRS with a presumed or confirmed infectious process**

- Sepsis

- SIRS

- Infection/Trauma

**Severe Sepsis**

- Adapted from: Bone RC, et al. *Chest* 1992;101:1644
- Opal SM, et al. *Crit Care Med* 2000;28:S81

## Sepsis: Defining a Disease Continuum

- Bone et al. *Chest* 1992;101:1644; Wheeler and Bernard. *N Engl J Med* 1999;340:207

- Sepsis

- SIRS

- Infection/Trauma

**Severe Sepsis**

**Sepsis with **** ********1 sign of organ failure**
**Cardiovascular (refractory hypotension)**
**Renal**
**Respiratory**
**Hepatic**
**Hematologic**
**CNS**
**Metabolic acidosis**

## Relationship Of Infection, SIRS, Sepsis Severe Sepsis and Septic Shock

**Notes:**
This conceptual framework shows the interrelationships between infection, non-infectious disorders, SIRS, sepsis and severe sepsis. Components of the process not discussed on the following slides include:
Infection: a microbial phenomenon characterized by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by those organisms
Bacteremia: the presence of viable bacteria in the bloodstream
Septic shock: sepsis-induced hypotension despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria or an acute alteration in mental status 
Multiple organ dysfunction syndrome (MODS): presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention

Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992;101:1644-55.
Opal SM, Thijs L, Cavaillon JM, et al. Relationships between coagulation and inflammatory processes. Crit Care Med 2000;28:S81-2.

## Mortality Increases in Septic Shock Patients

_**Incidence**_

- Balk, R.A. *Crit Care Clin* 2000;337:52

**Approximately 200,000 patients including 70,000 Medicare patients have septic shock annually**

## Definitions & Current Convention

**Sepsis** (currently included in 038.x)
- 	Systemic inflammatory response to known or suspected infection
**Severe Sepsis** (995.92 + 038.x)
- 	SIRS associated with organ dysfunction (failure), hypoperfusion, and perfusion abnormalities

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

## Definitions Continued

**Septic shock** (currently included in 785.59)
- 	A subset of severe sepsis, where patients experience combined decreased systemic vascular resistance and the presence of reduced myocardial performance

- Bone, et al. *CHEST* , 1992;101:1644

## Inadequacy of Existing Codes

- Septic shock is bundled with non-related diagnoses for non-traumatic shock in 785.59 including:
- Extracardiac obstructive shock
- Pericardial tamponade
- Constrictive pericarditis
- Pulmonary embolism
- Oligemic shock
- Dehydration
- Hemorrhage

- Parrillo JE. *Ann Intern Med*  1990;113:227

## Septic Shock is Unique within 785.59

**ICD-9-CM code 785.5X Population**

**785.59 Details**

**88,600**

**10,100**

**45,200**

**Septic Shock patients have a longer length of stay and a higher cost than other patients within 785.59**

*** ****Represents Septic Shock Patients**

|  | 
Population | 
Mortality | 
Length
Of Stay | 
Cost |
| --- | --- | --- | --- | --- |
| 
With infection * | 
70,900 | 
51% | 
17.1 | 
$30,300 |
| 
Without infection | 
17,700 | 
52% | 
8.9 | 
$17,400 |

**785.5**
**Unspecified**
**Shock**
**7%**

**785.51**
**Cardiogenic **
**Shock**
**  ****31%**

**785.59 Other Shock**
**62%**

## Create unique code to identify septic shock
785.52, septic shock
Use additional code (995.92) to identify severe sepsis
Remove term “septic” from 785.59, other shock without mention of trauma & 998.0, postoperative shock
Add “excludes septic shock (785.52)” from 998.0, postoperative shock
Add notation to 995.92 to code also “septic shock” (785.52)

- 785.52, *septic shock*
- Use additional code (995.92) to identify severe sepsis
- Remove term “septic” from 785.59, *other shock without mention of trauma *& 998.0, *postoperative shock*
- Add “excludes septic shock (785.52)” from 998.0, *postoperative shock*
- Add notation to 995.92 to code also “septic shock” (785.52)

- Modification to Septic Shock Coding

## Modification to SIRS Codes

- Sepsis should be indexed to 995.91, as it is defined as SIRS due to infection without organ failure
- Code also 038.x
- 995.92 should include link to the new Septic Shock code, as Septic Shock is a subset of  Severe Sepsis
- Modification will ensure adoption and proper use
- Without these modifications, valuable data on mortality, morbidity, and utilization will be lost

## Modification on SIRS Codes (Cont.)

- Include the following organ dysfunction examples under 995.92
- Respiratory failure 	(518.81)
- Acute renal failure 	(584)
- Hepatic failure 	(573.9)
- Septic shock 	(785.52)
- Delete heart failure under 995.92, as this is related to Septic Shock 	(785.52)

## Conclusion

- Septic shock has distinct characteristics that support the creation of a unique code (785.52)
- Septic shock should be linked to severe sepsis
- Modification of current SIRS coding will better represent the clinical presentation of the sepsis syndrome
-  995.51, *sepsis*
* *Modification to “code also” list in 995.92

## Slide 15

## Deficiencies of 1991 Consensus Conference

- Limitations inherent in these definitions:
- Incomplete agreement as to what defines “Systemic Response"
- Inflammation only?
- Organ/System failures not defined
- Except hypotension (SBP <90 mmHg or >40 mmHg decline from baseline; need for vasopressor support)

- "Dear SIRS, I do not like you"
*Jean Louis Vincent*

## 2001 Sepsis Definitions Conference

- Current definitions will remain unchanged
- However, will accept the uncertainty of definitions
- SIRS expanded to signs and symptoms
- Chills
- Alteration in temperature
- Tachypnea
- Change in mental status
- Tachycardia
- Altered WBC, Bandemia
- Thrombocytopenia
- Decreased perfusion: mottling, poor capillary refill
- Increased blood sugar
- Petichiae/Purpura

## 2001 Sepsis Definitions Conference

**PIRO** staging system proposed
**P**redisposition: 	  Genetics, Chronic illness
**I**nsult: 			  Infection, Injury, Ischemia
**R**esponse:		  Physiologic, Mediators, Markers
**O**rgan Dysfunction:  Outcome, Organ dysfunction

- To be published 2002 (Verbal communication Mitchell Levy, SCCM 2002)