Help with clarifying diagnosis

I have a physician that keeps documenting elevated lactic acid level and systemic inflammatory response syndrome (SIRS) criteria for sepsis, without septic shock.  The coder feels that there needs to be a query to clarify the diagnosis.  Any suggestions on how to query? 

Comments

  • SIRS + an infection does not = sepsis anymore. If there is a known or suspected infection and it appears that the patient is being treated for sepsis then I'd query for sepsis.

    Are these patients with infections or patients with other risk factors for SIRS such as burns, pancreatitis, etc...?

    Jeff

  • jwmorris1 said:

    SIRS + an infection does not = sepsis anymore. If there is a known or suspected infection and it appears that the patient is being treated for sepsis then I'd query for sepsis.

    Are these patients with infections or patients with other risk factors for SIRS such as burns, pancreatitis, etc...?

    Jeff


    The patient that I am dealing with today has a known infection.
  • I'd query for sepsis. The MD staff may need some education also.
  • I agree - the query is definitely needed.
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