Sepsis and Multi-organ Failure

tvansickle

This is a complicated case. The patient initially presented with an acute abdomen in ER and plan was for emergent surgery for the acute abdomen, while in surgery waiting the patient had a drop in BP and EKG changes and was taken to cath lab emergently for 100% occlusion. Post cath the patient was transferred to ICU and 30 minutes later went into PEA and was coded and then emergently taken to OR for an the acute abdomen. Physician documents sepsis in the OP Report and in the Progress Notes. They also document liver shock and multi-organ failure. Is there enough clinical evidence to code severe sepsis with shock without the physician documenting it or does a query need to be sent to the physician? 

evanspx@sutterhealth.org

The Coding Conventions (Index) states that Sepsis ‘with’ organ dysfunction (acute) is coded as Severe Sepsis - R65.20. Sepsis ‘with’ Shock is coded as Septic Shock - R65.21

The chart must literally use working such as Sepsis ‘with” Shock or Septic Shock or Sepsis causing Acute Renal Failure, or similar language in order to establish ‘linkage’.  Hope this helps.

Paul Evans, RHIA, CCDS

aimee_van balen_61052

I agree with Paul that the chart must directly link the Sepsis with the organ dysfunction. Also based on your statement I don't see evidence of septic shock - rather shock liver which has its own ICD10 code to capture the condition.

tvansickle

Thanks for the input.