Severe Sepsis
On page 155 in the 2017 CDI Pocket Guide regarding Severe Sepsis with organ dysfunction, can anyone clarify the "assumed" link of sepsis and a documented organ dysfunction would be coded to Severe Sepsis?
"Whenever there is documentation in the record of sepsis and a condition representing organ dysfunction (see above), it is now assumed that they are related, and the additional code for severe sepsis should be assigned unless the organ dysfunction is specifically atrributed to some condition other than sepsis". Reference OCG section I.A.15.
However, in the last paragraph of the severe sepsis section on the same page, it then says "Do not assign a severe sepsis code (R652x) if the acute organ dysfunction is not clearly associated with the sepsis. If unclear whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider (OCG I.C.1.d.a.iv.)".
It seems the book is saying 2 different things.
Comments
We have considered the new 'with' guidance but have opted to continue to ask/expect providers to make the link.
Katy
Still require linkage, even with the guidance cited per this message. Seems most prudent practice in my view.
Paul