Identifying Causative Organisms
To get to a more specific Sepsis code does the provider need to use linking terms between the organism and the diagnosis of sepsis (when there is only one identified infection present)?
Example of the provider's documentation:
Sepsis secondary to Pyelonephritis, present on admission, improving
-SIRS criteria met with Leukocytosis 13.6, febrile, tachycardic
-UA grossly positive
-CT abdomen demonstrating slight appearance that has been along the wall of the renal pelvises bilaterally as well as portions of the ureter suspicious for pyelonephritis
-Urine cultures positive E.coli sensitive to rocephin and cipro
Is the example above enough to link the E.coli to the Sepsis or is a query needed?