Case #673

Sepsis from 2020

Added by Mats Fernström 5 months ago. Updated about 1 month ago.

Status:AcceptedStart date:2020-01-30
Priority:MinorSpent time:-
Assignee:Mats Fernström
Category:-
Target version:NordDRG 2021
Initiator:Sweden Target year:2021
Case type:Minor Owner / responsible:National organisations
MDC:MDC18 Old forum status:
Target Grouper:EST, FIN, ICE, LAT, NOR, SWE

Description

In accordance with the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), the Swedish National Board of Health and Welfare has introduced new diagnosis coding instructions (valid from 2020-01-01) for cases with sepsis. Because of these new coding instructions there is a need for some small changes the NordDRG logic.
The new coding instructions (in short):
• The text to the ICD code R65.1 is changed from “SIRS with infectious origin with organ failure” to “Sepsis according to Sepsis-3 criteria”.
• For generalized septic infections, where there is no information on the source of the infection, codes for sepsis from ICD-10 chapter 1 are used.
• In these cases there is no need to use the additional code R65.1 ‘Sepsis according to Sepsis-3’.
This means that sepsis according to Sepsis-3 is included in the conditions for sepsis in chapter 1.
As a consequence, we can no longer retain the principle that the addition of the secondary diagnosis R65.1 leads to a complicated DRG. Coding twice of the same thing must not lead to a complicated DRG!
To achieve this we have to add all codes for sepsis to the exclusion list for COMPL 18G80, which is the COMPL value for R65.1. We have selected all codes with DGCAT 18M01 (Septicemia) in NordDRG 2020 but also added some other codes where inclusion criteria is sepsis, i.e. A2410 ‘Acute and fulminating melioidosis’ (with DGCAT 18M99) and O8500 ‘Puerperal sepsis’ (with DGCAT 14M99).
However, R572 ’Septic shock according to Sepsis-3 criteria’ also has COMPL 18G80 (Severe sepsis & shock- major CC) and addition of the sepsis codes to the exclusion list will have the effect that septic shock can’t complicate sepsis without shock, which we think is wrong. Thus we suggest that R572 gets a new COMPL (18G81 ‘Septic shock- major CC’). On the exclusion list for this COMPL we want only R572 ’Septic shock according to Sepsis-3 criteria’ and A483 ‘Toxic shock syndrome’. (Actually, it is unnecessary to have R572 on the exclusion list because the code has DGCAT 99M00 and cannot be used for principal diagnosis but we will have it on the list for principal reasons – it will make it clear that a diagnosis must not be able to complicate itself.)
With the new COMPL for septic shock we have to change the text to 18G80. We suggest “Sepsis according to Sepsis-3 criteria- major CC”.

As mentioned, in the work on this case we discovered that there are diagnostic codes that mean sepsis but they do not have DGCAT 18M01. For a better medical description, they should have 18M01. We have therefore analyzed how it would be in a cost perspective if we change DGCAT to 18M01. The analysis is presented in Appendix_C826.xlsx and it indicates that it is OK to change DGCAT from 18M99 to 18M01, but the code with 14M99 (O8500 Puerperal sepsis) should retain its DGCAT.
The suggestions in this case are supported by Olafr Steinum, specialist in infectious diseases.

Our suggestion in summary.
In the table compl. cat. (or the table dg in the new NDMS structure):
o The text to 18C80/18G80 is changed from “Severe sepsis & shock”/”Severe sepsis & shock- major cc” to “Sepsis according to Sepsis-3 criteria”/”Sepsis according to Sepsis-3 criteria- major CC”.
o A new COMPL, 18C81/18G81 Septic shock/Septic shock- major CC is inserted.
In the table compl. excl:
o The new COMPL 18C81/18G81 is inserted with the codes A4830 and R5720 in the column “code”.
o For the COMPL 18C80/18G80 all codes with DGCAT 18M01 are added in the column “code”, but also the following codes:
A2410 Acute and fulminating melioidosis
A2820 Extraintestinal yersiniosis
A3270 Listerial septicaemia
A4270 Actinomycotic septicaemia
B3770 Candidal septicaemia
O859/O8500 Barnsängsfeber/Puerperal sepsis
In the table dg the DGCAT 18M99 is changed to 18M01 for the following codes:
A2410 Acute and fulminating melioidosis
A2820 Extraintestinal yersiniosis
A3270 Listerial septicaemia
A4270 Actinomycotic septicaemia
B3770 Candidal septicaemia

Detailed technical changes are in the file TC_C826.xlsx.

The DRG changes are moderate. Less than 600 cases per year in Sweden will be grouped to DRG 416N/S10E (Septicemia age > 17 w/o cc) instead of DRG 416M/S10A (Septicemia age > 17 w mcc) or 416C/S10C (Septicemia age > 17 w cc) and very few cases (less than 100 per year) will go from different DRGs to a DRG for sepsis (416/S10).

Appendix_C826.xlsx (19.7 KB) Mats Fernström, 2020-01-30 15:12

TC_C826.xlsx (23.6 KB) Mats Fernström, 2020-01-30 15:12

TC_C826 Updated 2020-03-26.xlsx (23.6 KB) Mats Fernström, 2020-03-26 18:33

TC_C826 Updated 2020-04-02.xlsx (25 KB) Mats Fernström, 2020-04-02 19:51

Technical changes case #673-2.xlsx (22.6 KB) Martti Virtanen, 2020-04-06 14:33

2020-04-23_673_TC_from_NDMS.xlsx (16.8 KB) Kristiina Kahur, 2020-04-23 12:11

TC_C826 Updated 2020-05-07.xlsx (25.6 KB) Mats Fernström, 2020-05-07 14:37

History

#1 Updated by Kristiina Kahur 5 months ago

Finnish National DRG-Centre/Kristiina Kahur 24-2-2020

Finland does not have specific sepsis coding guidelines. Other than that this change seems clinically meaningful change to be introduced.

#2 Updated by Martti Virtanen 4 months ago

2020-03-04 Martti Virtanen
The proposal affects all versions and the countries have to agree on the changes. Otherwise I see no problem with the proposal.
The C and G are modifiers of the CC-category, see NDMS #662

#3 Updated by Mats Fernström 4 months ago

Mats Fernström 2020-03-26
During the meeting Martti suggested that the text to COMPL 18C80 should remain unchanged but with the new COMPL 18C81 'Septic shock' we cannot have 'septic shock' also in 18C80. Therefore I have changed the text to 18C80 to only "Severe sepsis". Se updated technical changes.

#4 Updated by Kristiina Kahur 4 months ago

Nordic Casemix Centre/Kristiina Kahur 27-3-2020

Thank you for clarification.
There are two codes in TC - R5710 and R5780 - which are not indicate as if the codes are for the SoS version. However, adding to those two codes COMPLEX 18C80 Severe sepsis, it means that Swedish codes R571 Hypovolemisk chock and R578 Annan chock will get through mapping this feature too.
Should those rows with codes R5710 and R5780 be deleted from the table? Or should the TC be corrected and rows with R571 and R578 be added with National comment "This row is for the SoS version"?

Edit (30.3.2020) - correct me if I am wrong, but seems that this part is missing in TC: "The new COMPL 18C81/18G81 is inserted with the codes A4830 and R5720 in the column “code”." Current TC have no information about added COMPL 18C81 to any dg code.

#5 Updated by Martti Virtanen 3 months ago

  • File Technical changes case #673.xlsx added

2020-04-01 Martti Virtanen
The technical changes were incomplete since the added complication categories were not listed in the dg-sheet. However, they are indicated in the text and I could therefore add them to the tables. However, the text is unclear whether the listed dx should have C- or G-level complication category. Therefore, they have now been given C-level (normal CC not major CC). If this is not right, it can be changed.
Attached is the techncial changes for combined codes.

#6 Updated by Mats Fernström 3 months ago

Mats Fernström, the National Board of Health and Welfare, Sweden 2020-04-02 (Swe ID C826)
You are right, Kristiina and Martti, my technical changes (TC) were incomplete. Thank you for observing that. Here, I will try to improve myself.
• The new complication category 18G81 ‘Septic shock- major CC’ is allocated to R5720 ‘Septic shock’ instead of the present 18G80. This change must be made in the table dg, which I forgot in my TC. (To Martti: It must be a G-level complication category because that is what R5720 has had for several years and we have no indications for a change of the level.)
• For the new complication category, 18G81, there must be an exclusion list even though it originates from a category of the type “without exclusions”. (We do not talk about complication categories without exclusions any more, which I think is right because there is always at least one exclusion.) R5720 ‘Septic shock’ is of course obvious on the list because the code must not be able to complicate itself. I added also A4830 ‘Toxic shock syndrome’ to the list because that is also a shock due to infection and two very similar conditions must not be able to complicate each other. I think that the exclusions for 18G81 was OK in my TC.
(I thought of adding also R5710 ‘Hypovolaemic shock’ and R5780 ‘Other shock’ to the list with the motivation that one shock must not be able to complicate another shock but I didn’t, because I think that septic shock is more severe and the effect of such a change has not been analyzed.)
• The existing complication category 18G80 cannot keep the name “Severe sepsis & shock- major CC” since R5720 ‘Septic shock’ shall not belong to that category any more. Since Martti did not like the original suggested name, I changed it to “Severe sepsis- major CC” in TC_C826 Updated 2020-03-26.xlsx but we have no indications for a change of the level G.
• As mentioned, we discovered that there are codes that mean sepsis but they do not have DGCAT 18M01. For a better medical description, they should have 18M01 and the analysis presented in Appendix_C826.xlsx indicates that it is OK to change DGCAT from 18M99 to 18M01. In this aspect, I think that my TC was correct.
• Since the codes for sepsis in chapter one of ICD-10 and the other codes that will have 18M01 instead of 18M99 now include “Sepsis according to Sepsis-3 criteria” (= the meaning of R6510) these codes must also belong to a complication category of the level G and they all do, except:
o A2410 ‘Acute and fulminating melioidosis’ (has no COMPL)
o A2820 ‘Extraintestinal yersiniosis’ (has 18C90 ‘Other severe infection’)
o A3270 ‘Listerial septicaemia’ (has no COMPL)
o A4270 ‘Actinomycotic septicaemia’ (has 18C90 ‘Other severe infection’)
For these four codes, I suggest the existing complication category 18G80 (like R6510) instead of none or 18C90 in my new TC.
• In my exclusion list for 18G80/18C80, I included R5710 ‘Hypovolaemic shock’ and R5780 ‘Other shock’ which was a mistake. Severe sepsis might complicate these types of shock. This is now corrected in my new TC.
• Conditions in the category 18C80/18G80 (Severe sepsis) are less severe than conditions in the category 18C81/18G81 (Septic shock) so they must not be able to complicate codes with 18C81/18G81. Thus, the exclusion list for 18C80/18G80 is completed with R5720 ‘Septic shock’ in my new TC. A4830 ‘Toxic shock syndrome’ was already on the list.
My new TC (TC_C826 Updated 2020-04-02.xlsx) is attached.

#7 Updated by Martti Virtanen 3 months ago

2020-04-06 Martti Virtanen
I uppdated the combined version technical changes.
I hope I caught the well grounded changes by Matts correctly.
There are also a couple of codes that switch complication category and thus the old must be inactivated.
(I thik the new NDMS would state an error in these cases)

#8 Updated by Martti Virtanen 3 months ago

  • File deleted (Technical changes case #673.xlsx)

#9 Updated by Kristiina Kahur 3 months ago

Nordic Casemix Centre/Kristiina Kahur 23-4-2020

This is a pretty challenging case to get everything correct in NDMS.
Based on different versions of TC and comments on this ticket I have made the changes in NDMS in 2021 tables as indicated in attached TC. Please carefully double-check if it makes sense and corresponds to desired changes. If not, leave a comment on this ticket if there is anything we should correct.

#10 Updated by Mats Fernström 2 months ago

Mats Fernström, the National Board of Health and Welfare, Sweden 2020-05-07 (Swe ID C826)
We have studied the file 2020-04-23_673_TC_from_NDMS.xlsx and have some objections.
In the table dg feat:
A2820 Extraintestinal yersiniosis. NDMS suggests COMPL 18C80 but it must be CC-level G, i.e. 18G80, because it is a kind of sepsis and all other codes for sepsis in grown-ups have CC-level G.
A4830 Toxic shock syndrome. NDMS suggests a change of the COMPL varval from 23G01 (Shock- major CC) to 18C81 (Septic shock). We have not asked for such a change and we think it is wrong. First of all, a change of the CC level from G to C is not motivated without any analysis and secondly, toxic shock does not mean that the patient has to have sepsis. Toxic shock can occur also from localized infections.
B3770 Candidal septicaemia. NDMS suggests a change of the COMPL varval from 18G04 (Candidiosis- major CC) to 18C80 (Severe sepsis). We have not asked for such a change and it is partly wrong. A change of the CC level from G to C is not motivated without any analysis but we accept a change to 18G80 because as it is now, Candidal septicaemia cannot complicate less severe candida infections, but it can complicate other codes for sepsis.
O8500 Puerperal sepsis. NDMS suggests a change of the COMPL varval from 14C05 (Other complication of delivery) to 18C80 (Severe sepsis). We have not asked for such a change and we are very uncertain if it is a good change or not. O8500 can include sepsis but according to the inclusion criteria it can also mean less conditions like endometritis or even just fever. We see a need for a proper analysis and until then we don’t want any change of the COMPL varval. This means also that we withdraw our suggestion that O8500 shall be on the exclusion list for 18C80/18G80. We will make a new case on O8500 for a possible change in the version for 2022.
In the table compl excl
R5710 ‘Hypovolaemic shock’ and R5780 ‘Other shock’. NDMS suggests these codes to be included in the exclusion list for 18C80 (Severe sepsis). That was also suggested in our first incomplete TC but it was a mistake. Severe sepsis might of course complicate these types of shock. Thus, R5710 and R5780 should not be on the exclusion list for 18C80.

Our last (hopefully) file with technical changes (TC_C826 Updated 2020-05-07.xlsx) is attached.

#11 Updated by Kristiina Kahur 2 months ago

  • Status changed from Active to Accepted
  • Target Grouper EST, FIN, ICE, LAT, NOR added

Nordic Casemix Centre/Kristiina Kahur 8-5-2020

Thank you for feedback.
Based on that the following corrections have been made in NDMS (2021 tables):
Dg code A2820 - COMPL 18C80 -> COMPL 18G80.
Dg code A4830 - COMPL 18C81 was removed and COMPL 23G01 was set active again.
Dg code B3770 - COMPL 18G04 remains inactive, COMPL 18C80 -> COMPL 18G80.
Dg code O8500 - COMPL 14C05 was set active again, COMPL 18C80 was removed, COMPLEX 18C80 was removed.
Dg codes R5710 and R5780 - COMPLEX 18C80 was removed.

#12 Updated by Kristiina Kahur about 1 month ago

Nordic Casemix Centre/Kristiina Kahur 26-5-2020

During the checking of the 2021PL0 version an error was found regarding the implementation of this change. It concerns Finnish and Estonian version and dg code B377 (B3770). With implementation of this change COMPL feature of dg code B377 was changed from 18G04 to 18G80. At the same time we noted that COMPL 18G80/18C80 was not used in FIN and EST version in earlier versions. It created the situation that dg code B377 did not complicate the cases in FIN and EST version anymore. To fix it, COMPL and COMPLEX 18C80/18G80 was added to FIN and EST versions and respective codes.

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