Linking Sepsis with acute organ dysfunction
Official Guidelines for Coding and Reporting:Septic shock is severe sepsis. In order to code severe sepsis not stated as septic shock, the chart must either state “severe sepsis” or link sepsis to an acute organ dysfunction that permits the use of the R-code for severe sepsis. A code from subcategory R65.2 severe sepsis, should not be assigned unless severe sepsis is documented or an associated acute organ dysfunction is documented. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.
We use EPIC at our hospital and when the physician chooses Sepsis with Acute Kidney Failure (or any other organ dysfunction) as the problem - EPIC assigns Severe sepsis code to the problem list. They have choices: Sepsis with AKI, ARF, Acute CHF etc; or Sepsis with no organ dysfunction; or Sepsis with septic shock.
I have had lengthy discussions with practitioners in explaining that linking terms need to be: due to, associated with, secondary to...etc.
Are there any other resources regarding the linking of Sepsis with associated organ dysfunction? I have read the 1 white paper available on ACDIS and my interpretation is that we need to query each time the physician chooses the Sepsis with ARF, etc. It is just mind boggling to me that EPIC this huge entity would be set up as such, making me question my thoughts.