Sirs/ Sepsis

Can anyone clarify this for me... If the patient has all the criteria for SIRS on admission and the physician documents the SIRS diagnosis with a pneumonia Dx, does the chart get coded to Sepsis without the physician actually documenting Sepsis? Is it a coding rule that it reverts to a sepsis diagnosis? I really appreciate any help anyone can give me.
Thank you,
Barbara Lefevre RN BSN CCDS
Saint Mary's Hospital
Waterbury, Ct.

Comments

  • edited May 2016
    Our criteria defines Sepsis as SIRS + Infection.

    If it is indicated that the patient's SIRS is due to the Pneumonia it will be coded as PDx of Sepsis and Pneumonia as SDx of Pneumonia w/SIRS code.
  • We always clarify with the physician if his intent of documentation of SIRS is "Sepsis due to the pneumonia." Although SIRS + infection technically may meet criteria for Sepsis we require the exact documentation of sepsis. In asking this clarification... our physicians automatically now know to write Sepsis. Greater documented specificity.
  • edited May 2016
    From CC 4Q2003:

    "If the terms sepsis, severe sepsis, or SIRS are used with an underlying infection other than septicemia, such as pneumonia, cellulitis or a nonspecified urinary tract infection, code 038.9 should be assigned first, then code 995.91, followed by the code for the initial infection. This is because the use of the terms sepsis or SIRS indicates that the patient's infection has advanced to the point of a systemic infection so the systemic infection should be sequenced before the localized infection. The instructional note under subcategory 995.9 instructs to assign the underlying condition first."

    Renee


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