Patient Appearance and Sepsis Criteria
There's no question that a full description of the patient's need for admission includes a notation of the signs and symptoms of illness...does the patient look sick, appear dyspneic, look toxic, is in distress? And it's also clear that such descriptors help "tighten" the chart in the case of audit. That being said, clinical definitions for problems such as sepsis often do not require such descriptions of clinical appearance to meet diagnostic criteria (and in the case of sepsis, that would apply to both Sepsis-2 and Sepsis-3); and our "point and click world seems to make "NAD" the default of the busy, time-challenged clinician. Does your coding/clinical validation practice require that the provider include a clinical description of illness as in the examples above, and if that description is not there...for example, a patient who has a qualifying SOFA score for Sepsis-3 but the doctor has clicked "NAD" on the Hx and Px...would you accept the dx of sepsis and code it accordingly, or would you leave that dx (and the $$$) on the table? (For purposes of this question, let's assume you've done a clinical validation query that was inconclusive...because a query or talking to the doctor is the easy answer). Thanks!
Comments
Ultimately, code assignment is based on physician documentation and as is stated in the coding guidelines, that documentation alone (statement of a dx) is sufficient for code assignment.
The issue with documentation of sx/sx not being consistent with the documentation of the condition being diagnosed may put the record at risk of denial but should not mean that you do not code the condition. When a dx is made (and meets UHDDS criteria), the options are to code or clarify, not simply omit.
Katy