Severe Sepsis - Hypoperfusion
Can documentation of "lactic acidosis or hyperlactatemia due to sepsis" be considered acceptable documentation of organ dysfunction without a need for additional clarification of specific organ dysfunction, such as circulatory system dysfunction, to capture the diagnosis of severe sepsis. Or should the provider document "Lactic acidosis due to hypoperfusion due to sepsis"? or what should be documented in the case of lactic acidosis that is attributed to sepsis, that will qualify for severe sepsis?
Case Review
53 y/o male, PMH: DMII uncontrolled, 2 week history of productive cough-white phlegm, fever, sweats and chills. Recent onset of dyspnea, worse while lying flat, orthopnea and bilateral lower extremity swelling. Assessment: Severe Sepsis 2/2 Rt 4th & 5th digit diabetic foot wound with associated gangrene. New onset heart failure, elevated liver enzymes with transaminitis, hyponatremia. Lab: Na+ 131, WBC 10.4, Hgb 11.3, Hct 34.9, Absolute Neutrophils 8.59, ESR 85, PT 17, INR 1.35, Glucose 306, BUN 26, Cl- 96, Albumin 2.7, Alkaline Phosphatase 192, ALT 89, AST 86, CRP 12.0 & 17.7, Lactic Acid 2.5, HA1c 12, BNP 4000.
Provider documented “Pt meets SIRS criteria with an elevated lactic acid and tachycardia with a source which makes him septic and the lactic acid makes it severe septicâ€
Case Review
53 y/o male, PMH: DMII uncontrolled, 2 week history of productive cough-white phlegm, fever, sweats and chills. Recent onset of dyspnea, worse while lying flat, orthopnea and bilateral lower extremity swelling. Assessment: Severe Sepsis 2/2 Rt 4th & 5th digit diabetic foot wound with associated gangrene. New onset heart failure, elevated liver enzymes with transaminitis, hyponatremia. Lab: Na+ 131, WBC 10.4, Hgb 11.3, Hct 34.9, Absolute Neutrophils 8.59, ESR 85, PT 17, INR 1.35, Glucose 306, BUN 26, Cl- 96, Albumin 2.7, Alkaline Phosphatase 192, ALT 89, AST 86, CRP 12.0 & 17.7, Lactic Acid 2.5, HA1c 12, BNP 4000.
Provider documented “Pt meets SIRS criteria with an elevated lactic acid and tachycardia with a source which makes him septic and the lactic acid makes it severe septicâ€
Comments
Best Regards,
Cari Merlina RN, BSN
Clinical Documentation Improvement Specialist
Revenue Cycle
Yampa Valley Medical Center
p.970.871.2425
f.970.875.2796
Cari.merlina@yvmc.org
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
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Press Ganey Sepsis Workflow-attached
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In order to 'code' severe sepsis, the documentation has to be explicit.
(Lactic Acid can be 7.1 and pt can have 70/30 w/ pt on pressors and failing to respond to Bundle Measures, but if the diagnosis of Septic Shock is not recorded, it can't be coded)
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