SIRS vs Sepsis

davisd2davisd2
in CDI Talk Archive
I need help with choosing SIRS vs Sepsis.
A.If a pt has pne and meets criteria for Sepsis do you code Sepsis? The problem is SIRS is the same criteria as Sepsis if an infection is present.
B.I get that when to code SIRS when no infection is present but do you use it when an infection is present?
C.What if the MD cannot find the source of infection do you code SIRS with Bacterial infection, unspecified organism type/site 041.9.
Thanks for your help

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    You have to link the infection to the SIRS in order to get to Sepsis. I would recommend you ask the provider if they suspect sepsis or is there another source of the SIRS. There was a good discussion about this recently on the ACDIS website, I just can't remember where I read it.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
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  • catladyrncatladyrn
    Sepsis is often defined as SIRS due to infection. If they say SIRS without linking it to an infection, you code SIRS, 995.90. If they say the SIRS is due to a noninfectious process, you code 995.93 or 995.94. If they say sepsis/SIRS with an unidentified infection, then you code 038.9 + 995.91. You can't code a bacterial infection unless the physician states it is a bacterial infection.
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