Severe Sepsis POA, Septic Shock NOT POA

If any part of the conditions reflected in the combination code were not POA, POA is  NO.  Does this apply to the R65.21 Severe Sepsis with Septic shock code?  So for example, When Severe Sepsis is documented and supported as POA but Septic Shock is NOT POA- the code is R65.21 Severe Sepsis with septic shock is assigned a  POA of No.

The Pneumonia Mortality Measure reflects-Principal discharge diagnosis codes included in the cohort if combined with a secondary diagnosis of pneumonia coded as POA AND No secondary diagnosis of severe sepsis codes as POA is present.  If patient presents with Severe Sepsis with Pneumonia and on day 2 of admission develops hypotension and put on pressors.  CDI queries for septic shock-this patient would fall into the Pneumonia Mortality Measure since the R65.21 Severe Sepsis with septic shock has a POA of NO? 



  • I can not comment on the Pneumonia Mortality Measure - however you are correct in that the Severe sepsis with Septic Shock code would have a POA of No. 

    If the shock indicators were developing on admission you could query to ask the MD if septic shock was Present/evolving on admission or developed after admission as an option to potentially capture it POA yes if applicable - just a thought!

    Good luck!
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