Severe Sepsis - Hypoperfusion

cphelan1cphelan1
in Clinical & Coding
Can documentation of "lactic acidosis or hyperlactatemia due to sepsis" be considered acceptable documentation of organ dysfunction without a need for additional clarification of specific organ dysfunction, such as circulatory system dysfunction, to capture the diagnosis of severe sepsis. Or should the provider document "Lactic acidosis due to hypoperfusion due to sepsis"? or what should be documented in the case of lactic acidosis that is attributed to sepsis, that will qualify for severe sepsis?

Case Review

53 y/o male, PMH: DMII uncontrolled, 2 week history of productive cough-white phlegm, fever, sweats and chills. Recent onset of dyspnea, worse while lying flat, orthopnea and bilateral lower extremity swelling. Assessment: Severe Sepsis 2/2 Rt 4th & 5th digit diabetic foot wound with associated gangrene. New onset heart failure, elevated liver enzymes with transaminitis, hyponatremia. Lab: Na+ 131, WBC 10.4, Hgb 11.3, Hct 34.9, Absolute Neutrophils 8.59, ESR 85, PT 17, INR 1.35, Glucose 306, BUN 26, Cl- 96, Albumin 2.7, Alkaline Phosphatase 192, ALT 89, AST 86, CRP 12.0 & 17.7, Lactic Acid 2.5, HA1c 12, BNP 4000.

Provider documented “Pt meets SIRS criteria with an elevated lactic acid and tachycardia with a source which makes him septic and the lactic acid makes it severe septic”

Comments

  • cari.merlina@uchealth.orgcari.merlina@uchealth.org
    edited March 2016
    I disagree with the MD documentation. The specific organ dysfunction needs to be documented (i.e. heart failure, hepatic failure, is there resp failure/ABG's? What is creatinine for possible ARF? ). The elev lactate doesn't identify the organ dysfunction, in my opinion. I can post the Press Ganey Sepsis Workflow that is helpful.

    Best Regards,

    Cari Merlina RN, BSN
    Clinical Documentation Improvement Specialist
    Revenue Cycle
    Yampa Valley Medical Center
    p.970.871.2425
    f.970.875.2796
    Cari.merlina@yvmc.org








  • katysuegood@gmail.comkatysuegood@gmail.com
    edited March 2016
    Is the information in the 'chart review' from the chart itself or are you summarizing? It says 'severe sepsis'. If the provider documents severe sepsis, this is what will be coded (unless there is no clinical validity and a query is placed). However, yes, I would want the specific organ dysfunction documented and if clinical indicators are present a query should be placed for the organ dysfunction. Lactic Acidosis can be an indication of shock, is this what the provider is pointing to???

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


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  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited March 2016
    Agree w/ Katy's stance....important concept is that the Core Measures are abstracted independent of other factors, whilst 'coding' is 100% driven my MD documentation.

    In order to 'code' severe sepsis, the documentation has to be explicit.

    (Lactic Acid can be 7.1 and pt can have 70/30 w/ pt on pressors and failing to respond to Bundle Measures, but if the diagnosis of Septic Shock is not recorded, it can't be coded)

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.412.9421



    evanspx@sutterhealth.org




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