Help me with this case, please.

cseluke

I need some help with a case. We did some internal clinical validation
reviews for sepsis principal diagnoses on short stays. Here is the case;



55 year old male patient admitted with non-healing lower extremity
surgical wound. Non-healing infected wound well documented as reason for
admission by locum hospitalist. No SIRS indicators POA. 2 day LOS.
Wounds cultured, antibiotics given. HD # 1, physician assistant
documents "Sepsis RLE with culture spec 4+ GPC on Gram stain" and
"Non-healing wound RLE". Locum hospitalist writes discharge summary and
documents infected wound as discharge diagnosis-no mention of sepsis
anywhere in chart. Coder queries post-discharge for sepsis POA. Locum
hospitalist writes on query form "Sepsis was POA". Sepsis is coded as
principal diagnosis.



Case reviewed by 2 physician reviewers. Both state sepsis cannot be
clinically validated.



Can this case be resubmitted with a corrected (and lower-weighted) DRG?



Cathy Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
149 North Street
Waterville, ME 04901
Phone (207) 872-1796
Fax (207) 872-1519
Cathy.Seluke@mainegeneral.org

"That's why erasers were put on pencils." --Robert Lovely c. 1960 when asked if he ever made
mistakes

kshumpert

Is the Locum still active at your hospital where the physicians that reviewed the chart can discuss it with them? If not, check with your medical staff department and find out what your policy is surrounding Locums. It may be that you take it to your chief of medicine for clarification. I would want it recoded.


Kathy
Kathy Shumpert, RN, CCDS

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Cell phone 765-432-3961
Fax 765-453-8152

vdavis2

Cathy,

I write appeal letters frequently for RAC and Commercial Denials, so this is what I would do in this situation. Ask the MD to addendum the discharge summary to include Sepsis, POA status, and reflect the clinical indicators that validate the patient had Sepsis (especially those that were present on admit.) I would also ask the MD to reference any documentation from the record that substantiates previous outpatient treatments, failed antibiotics, cultures, etc. that were tried prior to the patient being admitted to the hospital. This documentation can help validate a diagnosis of Sepsis (SIRS due to Infection). Truly, it is the MD has the ability to "diagnose" a condition based on his/her clinical opinion. With that said, the MD will have to support the diagnosis by documenting clinical indicators, treatments, plans, and concerns. If the patient didn't meet SIRS criteria on admission, the MD should be able to defend "Sepsis" with the other indicators that lead to the diagnosis of Sepsis.

Good Luck!
Vicki

Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com

"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

Unknown

Would it be more effective for CDI to reinforce the concepts of documentation reflective of the reporting of physician's clinical judgment, medical decison making and amount of physician work performed as elements of CDI? Trouble is we most of the time focus upon capturing CCs/MCCs and PDXs without the supporting explicit physician discussion in the record of how a diagnosis was arrived at. Ammunition for the RACs to second guess documentation and recoup money

vdavis2

Glenn-

Absolutely! Great idea!!! I would get the documentation needed for this case, and then use it as a concrete example for future educational purposes!!! MD’s should know that 1-2 words documented now can save 1-2 hours later! Those hours could then be spent with their patients! -Vicki