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MRA Thought of the Day – Don’t Be Fooled By Sepsis-Like Features

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Situation:

Lynn Salois, RHIT, CCS, CDIP, Director of Coding

Lynn Salois, RHIT, CCS, CDIP, Director of Coding

An elderly patient presents with altered mental status and fever. The patient is found to be hypotensive, with a respiratory rate of 22, WBC’s > 12,000 and elevated lactic acid. The documented impression in the history and physical and throughout the progress notes is sepsis like features.

For another patient with the same clinical picture, their documented impression might be signs and symptoms of sepsis or sepsis syndrome. Are these considered a confirmed diagnosis of sepsis?

Here are my thoughts…

  • Although the clinical indicators for sepsis are consistently documented and identified as sepsis like or sepsis syndrome, these are not a confirmed diagnosis of sepsis.
  • Coding Clinic 2nd Quarter, 2012, directs the coder to query the physician when sepsis syndrome is documented to determine the specific condition the patient is being treated for.
  • Communicate the need for a concise diagnostic statement of sepsis to your CDS team. The diagnosis must be consistently documented throughout the record, including in the discharge summary, with supporting clinical evidence, in order for a sepsis code assignment. The documentation must also clearly indicate whether sepsis was present on admission.

What are your thoughts?

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