Querying for a Diagnosis of Sepsis

Are Clinical Indicators Present to Support a Diagnosis of Sepsis?

One of the most challenging areas that coders face is knowing when to pose a physician query. Coders often see diagnoses indicated by, but not clearly stated in, the physician documentation. When clinical indicators within the documentation point to a diagnosis of sepsis that is not clearly documented by the physician, a query regarding the significance of the clinical indicators is appropriate.

What are the most common clinical indicators for sepsis and septic shock?

The table above only represents some of the clinical indicators that may be present but is not an all-inclusive list.

One of the most challenging areas that coders face today is knowing when a query is necessary. Coders see diagnoses that are documented by the physician in the medical record, and they want to be able to report the code for the diagnosis. However coders know they must clinically validate diagnoses and if they are not able to, query or get CDI or a physician liaison involved.

There is an OCG stating: “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

Does this mean coders may report any condition documented within a medical record?

No, of course not. All coders have seen copy/paste in medical records and problem lists that are brought in from previous admissions. When reporting a diagnosis, the condition must meet the reporting guidelines either for selection of PDX or as an additional SDX.  The statement in the OCG above doesn’t mean that there doesn’t have to be clinical indicators for a disease present at all, only that the physician  is not limited to a specific set of clinical criteria he can use to make a diagnosis. There are many “established” criteria for many diseases and sepsis is no different. At this time, there are three sepsis criteria that different physicians and facilities follow and will most likely change again going forward.

What makes this so hard for coders is that it is difficult to question a physician’s documentation. When conflicting documentation within the record is present, that is much easier because coders are just asking for clarification. If a coder asks a physician “does this patient really have sepsis?”, this could be a bad situation with a very negative outcome on the query. It is better to ask the physician what criteria were used to make the diagnosis of sepsis or involve CDI or a physician liaison for help with these. Physician education is needed, and if coders don’t query, then the facilities and physicians will not know that there is a documentation issue.

Coding Examples

To learn more and see specific coding examples, download our Sepsis Coding eBook.