severe sepsis

laura.jansenlaura.jansen
in Clinical & Coding
Does a physician have to document severe sepsis in order to code that or is it sufficient for the physician to link an acute organ dysfunction to the sepsis in order to code the severe sepsis. I have the following & am wondering if it is enough to capture severe sepsis in this patient? Any thoughts?

1. SEPSIS, CONTINUES TO IMPROVE.
She remains afebrile with a normal white count. The source is believed to
be urinary tract infection with Gram negative rods. Sensitivities are
still pending but should be back today.


4. ACUTE RENAL FAILURE.
I see no evidence of chronic failure in her history, and the daughter
confirmed that she had never heard this was the case. Her admission
creatinine is 2.1 and it has decreased to 1.7. This seems to be a clear
trend down and I suspect it is related to capillary leak associated with
sepsis initially, possibly some antibiotic effect now. I would like to see
this back to normal, being that she has no history but with the chronic
UTIs, I bet she does have an elevated creatinine as a baseline. If she
leaves tomorrow, this will have to be followed up as an outpatient.

Comments

  • Unknown
    edited May 2016
    If you put sepsis and ARF in the encoder it comes up with severe sepsis.

    Charlene



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  • kari.eskenskari.eskens
    edited May 2016
    If the sepsis is linked to an organ failure, the code for severe sepsis can be used without the MD documenting the term "severe sepsis". I would code severe sepsis in this case.

    Kari L. Eskens, RHIA
    BryanLGH Medical Center
    Coding & Clinical Documentation Manager


  • catladyrncatladyrn
    When I put sepsis through the encoder, it asks me if there is acute/multiple organ dysfunction and then it takes me to septicemia, 038.9 + severe sepsis, 995.92. Severe sepsis is in parentheses, which means those words don't have to be included for it to be coded. CC4Q03 states that severe sepsis is sepsis w/associated organ dysfunction. To me that makes them interchangeable. Seems like maybe your coders aren't seeing the link between the sepsis and the organ failure?

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • kwilliams@halifaxrmc.orgkwilliams@halifaxrmc.org
    edited March 2016
    Dr. Gold,

    Please help me with your response to my question...I am not getting it.

  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    Lona,

    YES, for us, it is due to the new Sepsis Campaign and early goal-directed therapy guidelines, treatment in ED, Sepsis screening in ED. Our sepsis Coordinator has done her job well! Unfortunately the providers now think it good enough to have an elevated LA and therefore supports Sepsis clinically. We have had to educate them that the CDI team continues to use the SIRS + Infection criteria-and that one entity needs doesn't define it for the entire institution.

    So, yes, we have written more "anti-queries" lately for substantiating the clinical criteria used to support Sepsis...

    Our policy guidelines continue to support what we need for the diagnosis...

    A lot of education goes along with this here...

    Juli

    Juli Bovard RN CCDS
    Certified Clinical Documentation Specialist
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    755-8426 (work)
    786-2677 (cell)
    "No Limit to Better......"
    [CCDS_pin_1inch]




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