Compliant

I have a question regarding compliance. The MD documented "suspected sepsis based on high lactic acid on admission" on the H&P.  No mention of sepsis on the rest of the record. The coder placed a query for clarification of suspected sepsis diagnosis.  MD replied "yes, suspected sepsis had resolved by the time my NP saw the patient".  The CM director sent an email to the MD. stating "We would need to capture Sepsis resolved on the discharge summary so it can be coded and included in the summary of diagnosis on the bill as well as capture the DRG. If it is still listed as probable or suspected, it doesn't carry over. If there are MCCs and CCs sepsis gives us a length of stay of 12.5 days. If there are no MCCs or CCs we are only reimbursed for 4 days. Big difference in reimbursement for providing care to this patient." The MD ordered an addendum to the discharge summary based on this.

Please advise!!!

Thank you!

Comments

  • Is the diagnosis (suspected sepsis) have clinical validation?  (WBC/HR, Temp, RR? along with description of toxic/septic/ill-appearing?) -- in addition to a high lactate? 

    If true, the uncertain diagnosis throughout the chart needs to be added to the discharge summary as an uncertain diagnosis or ruled out. 

  • In my opinion this is not a compliant query.

    Telling the physician that if he provides the diagnosis of sepsis the length of stay increases and reimbursement increases is considered leading. Basically the CM director is saying document this so we can get paid more.

    To me the ideal queries would have been for clinical indicators (Sepsis 2 or 3 depending on what your facility is using) and /or POA or was it resolved prior to admission.

    Cynthia Mead RN CCDS

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