Sepsis 3

tvansickle

Our facility has recently adopted the sepsis 3 criteria and it has caused some challenges between coding and CDI. According to the Sepsis 3 definition it basically states that you can't have sepsis without severe sepsis.Am I correct? CDI sent a sepsis validation. The attending's response was no severe sepsis. Sepsis was coded by the coder because the query only addressed severe sepsis. CDI is saying that sepsis shouldn't have been coded since you can't have one without the other. Coding is saying that the question was only for the severe sepsis. This type of question has been asked in the past with no issues on not coding the sepsis. I am not sure why this is now becoming an issue. 

I would gladly accept any guidance on this subject. 

ebraun

According to Sepsis 3 criteria, all sepsis is severe sepsis.  However, the coding world is not the same.  In coding, there are separate codes for sepsis and severe sepsis.  So if the physician said no severe sepsis, \the sepsis could still be coded. 

tvansickle

I do understand the coding world, but I think the issue is the facility has adopted sepsis 3 criteria so when a provider says no severe sepsis it means no sepsis at all. Am I wrong in my thinking, but if a facility has set certain guidelines as to how they are going to define sepsis,  then shouldn't the coders follow the facilities decision? 

evanspx@sutterhealth.org

VERY brief response:  Ideally, your medical staff has endorsed a firm definition for Sepsis.  It helps to ‘defend’ the condition if/when the chart documents all manifestations and acute organ dysfunctions associated with Sepsis.  There are a number of publications in the ACDIS library addressing this topic...search the resources folder and you should find some useful information.    Hint.  Our facility recognizes a type 2 MI associated with Sepsis as “Severe Sepsis”, even though this is not addressed in SOFA criteria. 

evanspx@sutterhealth.org

tvansickle said:

I do understand the coding world, but I think the issue is the facility has adopted sepsis 3 criteria so when a provider says no severe sepsis it means no sepsis at all. Am I wrong in my thinking, but if a facility has set certain guidelines as to how they are going to define sepsis,  then shouldn't the coders follow the facilities decision? 

sounds like coding and CDI leaders need to convene and adopt a common strategy.  If this has not happened, the coders are compelled to code Sepsis as this is documented.  

tvansickle

Thanks Paul! I was thinking that same thing.