severe sepsis
Is there a coding clinic out there that states sepsis with an associated organ dysfunction can be coded to severe sepsis without the physician actually documenting severe sepsis? I keep running into this lately where I think severe sepsis should be coded but in the end it isn't. Take the following diagnosis list. I thought severe sepsis would have been coded given the statement under the renal failure, but it was not.
1. ACUTE RESPIRATORY FAILURE SECONDARY TO PNEUMONIA.
He's continuing to require oxygen at this point but clinically is much
improved. Will wean the O2 if possible but he may require O2 at home and
we can assess that further tomorrow. Follow-up chest x-ray in a couple of
weeks when he's completed his therapy may be warranted.
2. SEPSIS SECONDARY TO PNEUMONIA.
This has resolved clinically and by lab evaluation. He's on PO Levaquin
now and will continue that to complete a ten day course.
3. RIGHT UPPER LOBE PNEUMONIA.
Follow chest x-ray in a couple of weeks is warranted.
4. RESOLVED ACUTE RENAL FAILURE.
I suspect this was from the sepsis and prerenal issues. His creatinine
today is 0.8.
1. ACUTE RESPIRATORY FAILURE SECONDARY TO PNEUMONIA.
He's continuing to require oxygen at this point but clinically is much
improved. Will wean the O2 if possible but he may require O2 at home and
we can assess that further tomorrow. Follow-up chest x-ray in a couple of
weeks when he's completed his therapy may be warranted.
2. SEPSIS SECONDARY TO PNEUMONIA.
This has resolved clinically and by lab evaluation. He's on PO Levaquin
now and will continue that to complete a ten day course.
3. RIGHT UPPER LOBE PNEUMONIA.
Follow chest x-ray in a couple of weeks is warranted.
4. RESOLVED ACUTE RENAL FAILURE.
I suspect this was from the sepsis and prerenal issues. His creatinine
today is 0.8.