Severe sepsis occurs when sepsis progresses and signs of organ dysfunction/failure develop. One site stated that approximately 30% of patients with severe sepsis do not survive. Patients may develop one organ dysfunction/failure, multi-system organ failure and/or septic shock.
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In Part 2 of our Sepsis Series, we are going to focus on sequencing of sepsis when the diagnosis is clearly documented. Later in the series we will look at what to do when the diagnosis is not clearly documented.
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In this series, we will learn what sepsis is or causes of sepsis, how to sequence the diagnosis in ICD-10-CM, what are the clinical indicators for sepsis, is a query necessary before reporting the diagnosis of sepsis, and how to prevent denials on sepsis records.
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Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?
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The majority of the recommendations from DRG 872 (Septicemia w/o mechanical ventilation 96+ hours w/o MCC) were to DRG 871 (Septicemia w/o mechanical ventilation 96+ hours with MCC) with the addition of an MCC to the account. Not all of these required a physician query and were present in the medical record documentation without any clarification needed prior to coding.
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