Septicemia, Sepsis, Systemic Inflammation

HCC 2

51 codes are included in HCC 2

The codes classify conditions

such as Salmonella meningitis, meningococcemia, toxic shock syndrome, hypovolemic shock, systemic inflammatory response syndrome, and sepsis (specified by organism and unspecified). 

B37.1, Pulmonary candidiasis

maps to both HCCs 2 and 6 in v24 and v28.

A number of conditions contribute to HCC risk adjustment

and most likely require an acute hospital inpatient level of care

A frequent error in reporting occurs when the patient is seen post-discharge in the primary care setting

and such conditions continue to be reported as active when a history code may be more appropriate

Such conditions have been identified by the Office of Inspector General as audit targets for Medicare Part C payments.

These conditions may be carried over in error because they are not listed as resolved in the problem list or because the provider is not fully aware of how to report a history code versus active disease.

providers should ensure that the diagnoses are currently being addressed and not better reported with a history code. As an example,

acute myocardial infarction (I21.9) represents a patient who has experienced a myocardial infarction (MI) within the last 28 days and is still being monitored and treated, whereas I25.2 indicates a patient with a history of an MI with no current acute treatment needs.

Additionally, many HCCs contain both conditions likely seen in the acute care setting and others that are chronic in nature and allow year-over- year reporting. For example,

HCC 213 Cardio-Respiratory Failure and Shock includes conditions only seen in the acute care setting as well as respiratory failure

The majority of these codes require a seventh character identifying the type of encounter (e.g., initial, subsequent, or sequela). Many providers are unaware of the meaning of the seventh character and inadvertently continue

to use the seventh character indicating an initial encounter when a different descriptor is more appropriate. Such an error may mistakenly allow an HCC to be reported that is not appropriate to the situation.

Although it would be rare to diagnose and treat sepsis in the outpatient setting, it is important for outpatient CDI efforts to ensure the capture of any associated diagnoses.

The patient may be discharged from the hospital with a resolved diagnosis of sepsis, but the underlying infection and any associated complications may still be active and under treatment.

sample query

Patient history indicates a hospital stay, discharged January 25, for sepsis secondary to pneumonia. The problem list, updated after February 2 office visit, lists sepsis as an active problem. Progress notes (2/2) describe the presence of dry cough, lung sounds clear, afebrile with antibiotics discontinued. Sepsis identified as the reason for the encounter. Please update the status of sepsis on problem list.

• Sepsis, resolved

• Sepsis is still active (please specify the treatment plan): ________________________

• Other (please specify): ________________________