sepsis and resp failure
Hi all,
We have some new (to us) coders and I am working a mortality case right now where we have Acute resp failure and sepsis and the coder has ARF as Pdx. She states that this is fine (in this case) because it was most extensively treated. Patient was on the vent.
This was a short admission, one day. The patient was elderly and moved to comfort care quickly. We never identified the source of sepsis.
I am confused here. I have always been under the impression that sepsis must be Pdx in these cases. Otherwise, we'd always sequence the ARF as Pdx considering it is the higher weight and often no surgical procedure is done for the sepsis or underlying infection.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
We have some new (to us) coders and I am working a mortality case right now where we have Acute resp failure and sepsis and the coder has ARF as Pdx. She states that this is fine (in this case) because it was most extensively treated. Patient was on the vent.
This was a short admission, one day. The patient was elderly and moved to comfort care quickly. We never identified the source of sepsis.
I am confused here. I have always been under the impression that sepsis must be Pdx in these cases. Otherwise, we'd always sequence the ARF as Pdx considering it is the higher weight and often no surgical procedure is done for the sepsis or underlying infection.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Comments
One really has, IMO, very limited options when sequencing Sepsis and the ARF in this particular situation. Again, this is my opinion.
Guidance issued in Coding Clinic 2003, 4th Quarter pertaining to the Chapter-Specific Guidelines for Sepsis/SIRS does not allow acute respiratory failure to be sequenced before Sepsis/SIRS if both are present at the time of admission.
I do not believe a sequencing option exists for a patient admitted with a localized infection that has progressed to septic shock, sepsis or SIRS, regardless of the source of the sepsis, be it a UTI, Decubitus Ulcer, pneumonia, or any other localized infection. It is this author's interpretation of current advice published in Coding Clinic, that when a patient is admitted with sepsis, pneumonia, and respiratory failure, sepsis is the principal diagnosis, regardless of the cause of the respiratory failure, be it sepsis or pneumonia, or of some other or of unknown etiology. Sequencing options sometimes exist when the record documents a situation in which "two or more diagnoses equally meet the criteria for principal diagnosis selection as determined by the circumstances of the admission and the diagnostic workup and the therapy provided".
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
All guidance I have seen points to Sepsis as the PDX.
See also Coding Clinic, Second Quarter 2005-septic shock, resp failure and h influenza pneumonia in which case the coder is directed to sequence the sepsis first.
Kerry
Kerry Seekircher, RN, BS, CCDS, CDIP
Would you maintain this is the ARF is not specifically connected to the sepsis?
Just bolstering my argument ;-)
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.94
Kerry Seekircher, RN, BS, CCDS, CDIP
I am not saying that Sepsis, when POA, is 'always' the PDX for all cases, as we have had instances whereby some very unfortunate individuals were admitted with sepsis and the staff also very clearly stated the pt had a concurrent acute stroke and/or AMI, with the AMI causing Cardiogenic shock and subsequent ATN, and the stroke causing acute respiratory failure (brain stem infarct) So, I believe (again, my opinion) it is possible to conceive very limited cases whereby Sepsis is present at admit, but not 'always the PDX. In such rare cases, Sepsis may not always be the PDX.
However, if a pt has, as one example Sepsis, PNA and Acute Respiratory Failure, I can't see how we can 'parse out' the acute respiratory failure as the PDX over the systemic illness....hope this makes some sense? We have disease of 'only' the lungs and Sepsis...how does the Sepsis not trump by definition of Principal Diagnosis?
We all know my background, (I stand by the coding profession) but I think the coder is on shaky ground with the reasoning on this particular issue. Your coder wishes to apply the principal below, but I don't concur.
Two or more diagnoses that equally meet the definition for principal diagnosis In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
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Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, February 09, 2016 4:51 PM
To: Kathryn Good
Subject: RE:[cdi_talk] sepsis and resp failure
Yes, I would...in that case, I'd argue that a Sepsis, being a 'systemic' illness, is of greater acuity than the disease that is limited 'only' to one organ, in this case, the acute respiratory failure.
I am not saying that Sepsis, when POA, is 'always' the PDX for all cases, as we have had instances whereby some very unfortunate individuals were admitted with sepsis and the staff also very clearly stated the pt had a concurrent acute stroke and/or AMI, with the AMI causing Cardiogenic shock and subsequent ATN, and the stroke causing acute respiratory failure (brain stem infarct) So, I believe (again, my opinion) it is possible to conceive very limited cases whereby Sepsis is present at admit, but not 'always the PDX. In such rare cases, Sepsis may not always be the PDX.
However, if a pt has, as one example Sepsis, PNA and Acute Respiratory Failure, I can't see how we can 'parse out' the acute respiratory failure as the PDX over the systemic illness....hope this makes some sense? We have disease of 'only' the lungs and Sepsis...how does the Sepsis not trump by definition of Principal Diagnosis?
We all know my background, (I stand by the coding profession) but I think the coder is on shaky ground with the reasoning on this particular issue. Your coder wishes to apply the principal below, but I don't concur.
Two or more diagnoses that equally meet the definition for principal diagnosis In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
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I'd be interested to know if you convince the coder to change the sequencing?
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01D16352.4EE147F0]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, February 09, 2016 3:54 PM
To: Evans, Paul
Subject: RE:[cdi_talk] sepsis and resp failure
Thanks Paul and Kerry!!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I will add that the physician must make the connection between the sepsis and the acute organ dysfunction.
Bottom line - I concur with Paul and Kerry...for what it's worth. It would be difficult to justify ARF over the sepsis.
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Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
The coder did agree to change the sequencing.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404