Severe Sepsis and hypotension

sarah_wicks@urmc.rochester.edu

In a chart that has severe sepsis and hypotension (not documented as being caused by something else), can you code both? There are no coding clinic or guidelines against it, but our coders are saying no, because hypotension is a symptom of severe sepsis. However, hypotension obviously isn’t inherent to sepsis. Any thoughts?

deanna-brennan@uiowa.edu

We’ve encountered this here too. Technically speaking hypotension is not seen in every sepsis case, however is a symptom of septic shock.  

If severe sepsis is documented clearly with supporting documentation and there is documentation of hypotension, my nursing brain says you should be looking for/querying for septic shock. However, in the absence of shock documentation and symptoms, yes, I would code the hypotension and the severe sepsis.   I did reach out to one of our SME coders and she agreed.

Deanna Brennan, RN, BSN, MBA CCDS

bawolfy@yahoo.com

I also support coding hypotension and severe sepsis if they coexist, regardless of whether or not the hypotension is due to sepsis (sometimes the physician links it to dehydration).  These patients are sicker and hypotension is a risk adjuster.  
Similarly, I consider hypotension inherent to septic shock and would not code it separately.
B

sarah_wicks@urmc.rochester.edu

Thank you both for your input. We really appreciate it!

evanspx@sutterhealth.org

I support coding hypotension as a separate finding if present and supported as it is not integral to sepsis.  I would not code it if some other process, such as shock, is present as this is redundant and over-coding.

P. Evans, RHIA, CCDS