Denial re sepsis without bacteremia

cdrum

Hello,

I was wondering if anyone had encountered any similar denials and how you approached it:

Pt was admitted w/ sepsis as noted by the attending provider in multiple notes including the discharge summary.  The clinical indicators for sepsis were not a slam dunk so to speak but were present nonetheless.  An ID consult was done where the doctor stated there was no bacteremia.  ID did not document sepsis but never stated there was no sepsis.  The denial states this is conflicting documentation and a query should have been sent for further clarification.  The auditor is also using the guidelines that state that "Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patient with clinical evidence of the condition; however the provider should be queried."  Obviously a query was not sent and the sepsis was coded as the pdx.

Anyone seen/experienced anything similar or could offer some thoughts?

Thanks!

kshumpert

Absence of documentation does not necessarily indicate conflicting documentation.  There is a coding clinic from 2014, Documentation Issues from Coding Clinic 1st Quarter, 2014 pages 11-13 that I often cite that states code assignment may be based on other physician documentation, as long as there is no conflicting information from the attending physician.  If the attending physician documented sepsis, that does not infer that the information is conflicting.  I also cite MLN Matters Number SE1121 from 7/31/2012 that states, "Remember that the "Coding Clinic, First Quarter 2004" states, if there is conflicting physician documentation, and the coder fails to query the attending physician to resolve the conflict, hospitals are encouraged to code the attending physician’s version. However, the failure of the attending physician to mention a consultant’s diagnosis is not a conflict. So, if the consultant documents a diagnosis and the attending physician doesn’t mention it at all, it is acceptable to code Page 3 of 3 it. A conflict occurs when 2 physicians call the same condition 2 different things – for example, the attending physician documents a sprained ankle and the orthopedist refers to the same injury as a fracture".

evanspx@sutterhealth.org

Positive blood cultures are not required for a diagnosis of sepsis, and most coders/ CDI know that more often than not, blood cultures are not helpul in efforts to diagnosis sepsis.  The premise of the auditor’s  argument is clinically false.