Archive for April, 2019

CODING SEPSIS: KNOWING THE SIGNS & SYMPTOMS

Posted by Samantha Serfass on April 16, 2019 in Blog, News

Coding Sepsis:  Knowing the Signs and Symptoms

Sepsis is the body’s extreme response to an infection. It occurs when an infection you already have in your skin, lungs, urinary tract, or somewhere else triggers a chain reaction throughout your body. Anyone can get an infection, and almost any infection can lead to sepsis including bacterial, viral or fungal infections.

Globally, an estimated 20 million to 30 million cases of sepsis occur each year. Hospitalizations for sepsis have more than doubled over the past 10 years, and the incidence of sepsis developing after surgery tripled from 1997 to 2006. Mortality from sepsis is estimated to be greater than mortality from AIDS and breast cancer combined.

Common signs and symptoms of sepsis:

  • Altered mental status, drop in urine output, and decreased capillary refill of nail beds or skin
  • Fever (temperature greater than 100.4 degrees) or hypothermia (temperature less than 96.8 degrees)
  • Leukocytosis (white blood cell count greater than 12,000) or leukopenia (white blood cell count less than 4,000 or greater than 10% bands)
  • Hypotension (systolic blood pressure < 90 mm Hg or fallen by > 40 from baseline, mean arterial blood pressure < 70 mm Hg)
  • Lactate >1 mmol/L.
  • Tachycardia (greater than 90 beats per minute)
  • Tachypnea (respiratory rate greater than 20 breaths per minute or a pCO2 of less than 32 mmHg)

Coding a patient’s record with sepsis can prove challenging for medical coders. For example, the ICD-10 Official Coding Guidelines tell us signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. If the patient is admitted with a localized infection and sepsis, the code for the systemic infection should be assigned first, followed by a code for the localized infection. If the patient is admitted with a localized infection, and develops sepsis after admission, a code for the localized infection is assigned first, followed by a code for the sepsis.

A systemic infection can occur as a complication of a procedure or due to a device, implant or graft. This includes systemic infections due to wound infections, infusions, transfusions, therapeutic injections, implanted devices, and transplants. 

When sepsis is complicating pregnancy, childbirth, or the puerperium, the obstetrical code is sequenced first, followed by a code for the specific infection.  When a newborn is diagnosed with sepsis, a code from category P36 Bacterial sepsis of the newborn is assigned.

Both the coding guidelines for sepsis as well as ambiguous provider documentation often mean coders require an extended length of time to review a record – only to place it on hold for a physician query. It is up to the physician’s clinical judgement to decide whether the patient has sepsis.  The coder cannot assume the patient has sepsis based on criteria being met – they must rely on the physician’s documentation. Coders should emphasize to physicians the importance of capturing patient severity which will be reflected in accurate coding and correct facility reimbursement.

From a patient’s perspective, there are ways to help prevent sepsis.

  • Get vaccinated. According to a recent CDC study, 35% of sepsis cases stemmed from pneumonia. Annual flu shots can also prevent respiratory infections that often turn septic.
  • Treat urinary tract infections promptly. A quarter of sepsis cases resulted from urinary tract infections. It is important to see a healthcare provider if you have warning signs of those infections including a painful burning feeling when urinating and a strong urge to ‘go’ often.
  • Clean skin wounds properly. About one in 10 sepsis cases follows a skin infection. It is essential to care for wounds and scrapes properly – washing with soap and water, cleaning out any dirt and debris, and covering wounds. 
  • Avoid infections in hospitals. Insist that everyone who comes into your hospital room, including doctors and nurses, wash their hands before they touch you.

Knowing the signs and symptoms of sepsis is a medical coder’s first step towards accurately coding what can be a life-threatening illness. Coders should take the time to thoroughly review and learn from these records rather than be overwhelmed by them. 

It is also important to review how to apply sequencing guidelines and to query the physician for any ambiguous or conflicting information present in the patient’s record.

Cynthia Alder-Smith RHIT, CCS

Auditor/Coding Educator

Epic Community Connect: Planning the Right Approach

Posted by Samantha Serfass on April 3, 2019 in Blog, News

Epic Community Connect: Planning the Right Approach

Epic Community Connect: Planning the Right Approach

The need to extend EHRs to affiliates is increasing along with the integration needs of ACOs.  Epic Community Connect is a methodology and approach to extend EHR systems to partners and clients.  Community Connect can be licensed to both clinics and hospitals typically working with smaller budgets.  It’s crucial to understand the impacts of offering Community Connect as a host so no surprises arise in the process.

UNDERSTANDING THE COSTS

Identifying the cost to license Epic and its 3rd -party applications is an important factor to consider before offering Community Connect to providers.  Cost models for Community Connect can be very complex.  In the outpatient area, the costs are typically identified per physician.  A common price might be $15,000 per physician, but what might be a surprise is the complex costs of the 3rd parties.  For each 3rd– party application, health organizations need to revisit the contract. Every contract can be priced out differently for example:

  • SureScripts may have little to no costs for outpatient, however inpatient is based on the number of beds
  • For OBIX Electronic Fetal Monitoring, the cost is based on the number of births per year along with a one-time fee and a yearly support cost
  • For Patient Education & Discharge instructions from Elsevier, it may be based on the number of AVEs (Epic’s calculation of volume licensing)

Each hospital system has a different contract with not only Epic but with the many 3rd-party supporting applications, which have to be considered again before offering Community Connect to the community.  Health systems offering Community Connect without considering all the costs could end up with budget cuts, program delays and staff layoffs.

Excite’s Community Connect cost model includes the quadratic equation to help identify an accurate per physician cost and support needed to purchase Community Connect. Once a health system has implemented the EMR and its 3rd parties, each physician moving forward will require less support.

DEVELOPING A GO TO MARKET APPROACH

The amount of effort required by the receiver of Community Connect also depends on how the host organization packages the service offering to the market.  For example, if the receiving client is going to need to increase their IT security infrastructure to meet the hosts standards, additional resources will be needed.  However, if the host packages the offering to include the security services to ensure it is completed accurately, then that will also impact the effort for the receiving party.  Security is just one example but there are many others, such as:

  • Reporting
  • Training
  • 1st Level Support
  • Informatics

Smaller hospitals and clinics often don’t have additional staff to assist with an EMR implementation.  It’s vital for the health organization to recognize the Community Connect receivers time, effort and resources needed during implementation, especially if customization to the system is required. The key questions that host health organizations need to consider are:

  • Where can customization occur, and what will it impact for the implementation and support?
  • What is the cost and how much time and effort will be required?

SETTING EXPECTATIONS

While there is no one single method in setting expectations, the most important tool is a Detailed Project Plan. The plan should identify activities for the host, as well as the foreseen activities for the recipient.  Incorporating resources and estimated times of effort for activities can help assist in identifying the overall time the client will have to spend to implement the new system.

Developing a governance structure where Community Connect clients have a voice will help support the partnership. Expectation setting also requires guiding principles that both parties can embrace during the implementation and support phase. Strong communication is key to help reduce anxiety and concerns. When issues or concerns are escalated up through governance, guiding principles will need to be looked at and leveraged regularly.

Finally, when considering being a Community Connect host, it’s important to conduct a pilot first.  Conducting a practice run (or pilot), is where a host organization can identify the challenges they may face.  As a host, the health organization will now be a vendor providing a service, which is new to many organizations.

These elements all contribute to a successful Community Connect implementation. It’s important to consider all aspects of the project before offering Community Connect.

Todd Klein

VP EHR Services & Digital Solutions