Sepsis Case

lrubin

I would like the opinions of the group on a sepsis case I was asked by the coder to perform a retrospective review to see if I felt sepsis was the principal diagnosis vs. cellulitis with a infected diabetic foot ulcer. I reviewed the record which involved a 65 yo diabetic who presented to the ED with a a diabetic ulcer that was erythemadous and per patient his temp at home had been 101.In the ED the patient was afebrile,P 99 and RR WNL, WBC 25,lactade 1.4 He was started on IV vancomycin as he has a history of MRSA. With in 13 hours (the next time his WBC count was drawn) his WBC was 11 and his leg was improving.I looked at his respiratory rate through the etirehospitalization and it went from a low of 94 to a high of 99.

The H and P,d/c summary and first progress note said sepsis and then the diagnosis fell of.ID was writing cellulitis as the attending on subsequent notes.

Would love to see what CDI RN's,CDI coders, coders and anyone else on CDI talk thinks.

Thanks
Lois Rubin

cmorell

The temp of 101 and the WBC 25 are 2 of the 4 SIRS indicators. I would review the record to see if there were more. SIRS documented as due to infection supports code assignment of 038.9 and 995.91. If Sepsis is documented and POA then it should be sequenced as the PDx with the localized infection sequenced as a secondary diagnosis per coding guidelines.

However, based on the above information my recommendation would be to issue a query to the Attending provider:

Sepsis is documented in the H&P and the hospitalist progress note dated xx/xx/xx but not in subsequent progress notes or on the ID consult.
Based on your clinical judgment please clarify if Sepsis was ruled in, Sepsis was ruled out, cellulitis only, unable to clinically determine or other more appropriate diagnosis.

Clinical indicators: Medical Record Location:
Temp 101
Temp 99
WBC 25
IV Vanco
Lactic acid 1.4


Charlie Morell

katysuegood@gmail.com

I think the pt technically meets sepsis criteria. I would query with our 'not in discharge summery' query with the options of. Ruled in/resolved, ruled out, other, unable to determine....or something to that effect.

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

cindy.pritchett04

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What was his LOS and did he have any bands present on his CBC? Thx.

Cindy Pritchett, RN, BSN, CCDS
MedPartners CDI Consultant
On Tue, Oct 28, 2014 at 9:44 AM, CDI Talk wrote:

> I would like the opinions of the group on a sepsis case I was asked by the
> coder to perform a retrospective review to see if I felt sepsis was the
> principal diagnosis vs. cellulitis with a infected diabetic foot ulcer. I
> reviewed the record which involved a 65 yo diabetic who presented to the
> ED with a a diabetic ulcer that was erythemadous and per patient his temp
> at home had been 101.In the ED the patient was afebrile,P 99 and RR WNL,
> WBC 25,lactade 1.4 He was started on IV vancomycin as he has a history of
> MRSA. With in 13 hours (the next time his WBC count was drawn) his WBC was
> 11 and his leg was improving.I looked at his respiratory rate through the
> etirehospitalization and it went from a low of 94 to a high of 99.
>
> The H and P,d/c summary and first progress note said sepsis and then the
> diagnosis fell of.ID was writing cellulitis as the attending on subsequent
> notes.
>
> Would love to see what CDI RN's,CDI coders, coders and anyone else on CDI
> talk thinks.
>
> Thanks
> Lois Rubin
>
>
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> regulations related to documentation and coding, please refer to your
> regulatory source.
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> You are receiving this message as a member of CDI Talk as:
> cindy.pritchett04@gmail.com
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>

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What was his LOS and did he have any bands present on his CBC?=C2=A0 T=
hx.
=C2=A0
Cindy Pritchett, RN, BSN, CCDS
MedPartners CDI Consultant

On Tue, Oct 28, 2014 at 9:44 AM, CDI Talk <cdi_talk@hcprotalk.com> wrote:

I would like the opinions of the grou=
p on a sepsis case I was asked by the coder=C2=A0 to perform a retrospectiv=
e review to see if I felt sepsis was the principal diagnosis vs. cellulitis=
with a infected diabetic foot ulcer. I reviewed the record which involved =
a=C2=A0 65 yo diabetic who presented to the ED with a a diabetic ulcer that=
was erythemadous and per patient his temp at home had been 101.In the ED t=
he patient was afebrile,P 99 and RR WNL, WBC 25,lactade 1.4=C2=A0 He was st=
arted on IV vancomycin as he has a history of MRSA. With in 13 hours (the n=
ext time his WBC count was drawn) his WBC was 11 and his leg was improving.=
I looked at his respiratory rate through the etirehospitalization and it we=
nt from a low of 94 to a high of 99.

The H and P,d/c summary and fir=
st progress note said sepsis and then the diagnosis fell of.ID was writing =
cellulitis as the attending on subsequent notes.

Would love to see w=
hat CDI RN's,CDI coders, coders and anyone else on CDI talk thinks.
=

Thanks
Lois Rubin


---
CDI Talk is offered for networki=
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If you would like to be rem=
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leave-cd=
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---Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923



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deanne_wilk

I would place the query stating sepsis was documented with your notes as listed and ask if sepsis is still present, resolved or ruled out and ask to please amend document as such in discharge summary.

lmcnamara@cortlandregional.org

In this case we might query if the dx of Sepsis was ruled in, ruled out, resolving, resolved or still to be determined or none/unable to determine…just to show you all of our options.

I agree with the question of LOS and bands as well to help determine.

lrubin

The patient did not have a temp in the ED or during his 6 day stay.His WBC was 25 with 5 bands,13 hours later the WBC was 11.6 with no bands.We will be retro quering in the future due to the diference in opinion .