Sepsis transfer
I am full of questions today...
Patient was treated for sepsis (+ blood cultures) 2/2 to choledocholithiasis with biliary stones at an outside hospital. He was treated for 4 days and then transferred for ERCP (they were also suspicious of endocarditis but this was later ruled out). While hospitalized at our facility his vitals and WBC's were always stable with no SIRS criteria and blood cultures taken on admission were negative. However, documentation states 'klebsiella septicemia' throughout the record.
From a clinical perspective, is it defensible to stick with sepsis since the patient did have sepsis at the first hospital and was continued on ABX for the underlying infection during hospitalization. Or, would it have been better to query to clarify whether the inflammatory response was resolved prior to transfer making the localized infection the Pdx? I am wondering if a chart like this is a denial risk if coded as sepsis.
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Patient was treated for sepsis (+ blood cultures) 2/2 to choledocholithiasis with biliary stones at an outside hospital. He was treated for 4 days and then transferred for ERCP (they were also suspicious of endocarditis but this was later ruled out). While hospitalized at our facility his vitals and WBC's were always stable with no SIRS criteria and blood cultures taken on admission were negative. However, documentation states 'klebsiella septicemia' throughout the record.
From a clinical perspective, is it defensible to stick with sepsis since the patient did have sepsis at the first hospital and was continued on ABX for the underlying infection during hospitalization. Or, would it have been better to query to clarify whether the inflammatory response was resolved prior to transfer making the localized infection the Pdx? I am wondering if a chart like this is a denial risk if coded as sepsis.
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Comments
Fran~
Sepsis and documentation issues - notice
Coding Clinic, First Quarter 2012 Page: 19 Effective with discharges: April 1, 2012
Question:
The patient was transferred to the long term care hospital (LTCH) following a lengthy hospitalization for sepsis and acute respiratory failure. She was transferred to the LTCH for further intravenous antibiotic treatment and management of her multiple medical problems including resolving coagulasenegative staphylococcus sepsis, and respiratory failure. Since the sepsis is resolving would it be appropriate to code sepsis as the principal diagnosis? The ICD-9-CM Official Guidelines for Coding and Reporting do not address this issue.
Answer:
The Editorial Advisory Board (EAB) for Coding Clinic has become aware of a pattern of documentation problems concerning patients transferred to the LTCH with a diagnosis of sepsis. Physician advisers reviewing these cases did not agree that these patients were truly septic since they had no clinical indicators. If the documentation is unclear as to whether the patient is still septic, query the provider for clarification. Facilities should work with the medical staff to improve physician documentation and address any documentation issues. Please refer to the Fourth Quarter 2003 issue of Coding Clinic, pages 102-103, for additional information regarding coding and reporting for long term care hospitals.
Sharon Salinas, CCS
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
ssalinas@barlow2000.org
1. SEPSIS is not Septicemia
2. Septicemia w/o a code for SIRS is valid coding
3. If the pt is now on day 4 of X (?) for Septicemia, the septicemia is still an active problem undergoing treatment at your site - it is 'resolving', not resolved.
4. I would 'assume' the SIRS (Septicemia with at least 'some' organ dysfunction) is no longer 'active' as any organ manifestations of the SIRS, such as encephalopathy or acute renal failure, 'should' have been treated at the original acute care site and are now resolved or are 'resolving'. Pt send to you in a stable condition.
5. Pt was 'stable' at OSH site, SIRS should probably not be active or present or coded, but the pt does have SEPTICEMIA?
6. Positive B/C are not required to code Septicemia
The concept of coding active infections on transfer would be valid for other conditions, such as UTI or PNA, IF the patient is completing a course of treatment for said infection, IMO.
There are probably explicit references speaking to this scenario in Coding Clinic, but I have no time for a search today.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Thanks for setting me straight!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org