Severe Sepsis
Hi everyone,
I have a couple questions on the coding/documentation of severe sepsis.
1. If you have documentation of thrombocytopenia 2/2 sepsis would you code this as sepsis-related organ dysfunction?
2. If the patient has elevated Cr, our providers DO typically document renal failure. However, when bilirubin is elevated, they rarely document liver failure/dysfunction. Are you querying for this to support the dx of Severe sepsis?
thanks!
Katy
Comments
I believe the Coding Guidelines for severe sepsis allows the coders to code severe sepsis if the doctor relates the organ dysfunction to the sepsis. Ex: transaminitis due to sepsis. Our coders believe they cannot code 'severe sepsis' without the doctor saying those words. Do you query for them to say 'Severe sepsis' if they have already related the organ dysfunction to sepsis?
I think our coder's would generally code severe sepsis if the MD documentation states AKI due to sepsis or respiratory failure due to sepsis.
Someone please correct me if I'm wrong, but with the new "with" guidance issued by Coding Clinic can't severe sepsis be coded when the patient has sepsis and an organ dysfunction that's not stated due to another cause? If you go to the index it has sepsis with acute organ dysfunction.
Any thoughts?
Thanks,
Jeff
The issue I see is that our coders don't necessarily pick up transaminitis or thrombocytopenia as 'organ dysfunction'. They are not included in the list in the encode (I don't necessarily thing this is an exhaustive list) and therefore do not pick this up as 'severe sepsis'. Not AKI, resp failure, enceph, etc 2/2 sepsis, they would pick up as severe sepsis.
Jeff, yes technically the new guidelines would suggest that. I am not overly comfortable with this guidance though. I am still advocating for us to clarify this connection.
Katy
Bilirubin can be due to other reasons unrelated to sepsis
are you saying that in all cases? Because we can certainly code severe sepsis when it is not documented, if organ failure is tied to sepsis.
The new 'with' interpretation is sticky in my mind, but we do have clear guidance to code severe sepsis when we have sepsis related organ dysfunction regardless of whether they actually say 'severe sepsis'. We are no longer even advocating for using the term 'severe sepsis' since it does not exist in Sepsis-3.
Katy
Agree w/Katy, Sepsis causing acute organ dysfunction is coded as severe sepsis. However, must acknowledge there currently does not seem to be a universal 'list' of acute organ dysfunctions that when a consequence of sepsis equate to Severe Sepsis...that is the tricky part.
Paul Evans, RHIA, CCDS