sepsis validation
Our CDI team has recently been asked to validate every sepsis diagnosis at our facility. A report is generated in epic when the sepsis order set is initiated. We are being asked to use this report to reach out to the physician 24 hrs after admission to validate the sepsis diagnosis. The reason for this is a belief that pts are being final coded with sepsis when they truly did not have sepsis. I understand querying for clinical validation. But if the pt. has the clinical indicators for sepsis, treatment, etc., I do not see how we can compliantly query for diagnosis. Has anyone else been asked to do anything like this?
Thanks
Comments
Very brief response: I interpret your question as having two elements. In one element, Sepsis is stated, documented, MEETS your site's clinical criteria, and it is subsequent coded. In this situation, there is no need for further CDI interaction as you have confirmed clinical criteria as stated by your site's definition is present - it would seem you can defend the documentation and coding as your clinical definition is met. In this situation, you take no further action.
Situation two: Sepsis is stated and perhaps coded, but the standard (and approved and vetted) clinical criteria favored by your facility is lacking. For these cases, you would need to ask the MD to modify the record and perhaps indicate that, after study, sepsis was ruled out. Alternatively, the query could request additional documentation of clinical data and/or clinical decision-making by the provider to support the diagnosis. If the record lacks evidence-based criteria for a diagnosis, we must query. The MD should be provided the opportunity to either add more criteria to support the condition, confirm it as it stands, or confirm it was ruled out. REF: ACDIS White Paper: Clinical Validation
Paul Evans, RHIA, CCDS, CCS, CCS-P
Thank you. I am in total agreement.