need examples of when sepsis doesn't have to be p. dx

sanche

I am looking for some examples of when Coders could use sepsis not as the p.dx except procedural complications? thanks

Chris Marcus-Sanchez, RN, RHIT, CCS
Clinical Documentation Coordinator
Health Information Management
Holland Hospital
(616) 394-3581
Sanche@hollandhospital.org

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catladyrn

It's hard for me to think of concrete examples that don't involve complications, but sepsis, even with sequencing guidelines, still has to meet the definition of principal diagnosis. Maybe someone hit by a bus on the way home from the hospital after being treated for sepsis due to UTI, not completely resolved?


Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

ssalinas

Septicemia (sepsis) would not be principal diagnosis if it develops after admission such as the example below, the sepsis developed as a result or the injuries/treatment or compromised condition. Or a patient comes with some illness (MI, CHF, etc) and develops sepsis due to PICC or other line (CC 4th Qtr 2008). Or patient comes in with pneumonis, UTI or ? and sepsis develops after admission - may need to query for this one depending on the timing (CC4th Qtr 2008). There are other examples in CC such as 3rd Qtr 2008 pp13-14,

In all these cases sepsis does not meet the definittion of principal diagnosis.

sanche

thanks Renee-what are your thoughts about when the patient comes in with Acute respiratory failure, COPD exac and sepsis (all POA) and after query, the provider states the ARF is not an organ dysfunction for the sepsis but it is linked to COPD exacerbation. Can the ARF/COPD be the p.dx instead of sepsis?

Chris Marcus-Sanchez, RN, RHIT, CCS
Clinical Documentation Coordinator
Health Information Management
Holland Hospital
(616) 394-3581
Sanche@hollandhospital.org

catladyrn

Sharon, I think Chris was asking how not to take sepsis as pdx when it's clearly POA and it's not bundled to a complication code.

Chris, first I think I'd make sure that they really mean sepsis and not just SIRS. If there's no documented infection, confirmed or suspected, then it's not really sepsis, but just SIRS. But here is some more, better information--

4Q08: "If sepsis or severe sepsis is present on admission, and meets the definition of principal diagnosis, the systemic infection code (e.g., 038.xx, 112.5, etc.) should be assigned as the principal diagnosis, followed by code 995.91, Sepsis, or 995.92, Severe sepsis, as required by the sequencing rules in the Tabular List. Codes from subcategory 995.9 can never be assigned as a principal diagnosis. A code should also be assigned for any localized infection, if present."

http://www.fortherecordmag.com/archives/ftr_071204p31.shtml :

"Therefore, if a patient is admitted with sepsis, pneumonia, and respiratory failure, then the sepsis will more than likely be sequenced as the principal diagnosis as it is the acute condition causing the respiratory failure. However, if the documentation specifically supports that the respiratory failure was caused by another respiratory condition and not caused by the sepsis, then it may be appropriate to sequence the respiratory failure as the principal diagnosis."

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

lauriehiggins

Now Chris, don't get me started.