Sepsis After Careful Study

According to the CDC, “Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have —in your skin, lungs, urinary tract, or somewhere else—triggers a chain reaction throughout your body. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.”

Sepsis begins with an infection and can end far worse.  It is also one of the diagnoses that is often not clearly stated in the medical record. The clinical evidence may exist but for reporting it, the physician has to be clear.  Therefore, it is important for coders, CDI and others to see the clinical evidence for appropriate capture of the patients severity of illness that leads to accurate reimbursement.

Interpreting the story in the medical record has become somewhat difficult with challenges faced by carry forward information that causes problems with determining whether a condition exist and by lack of clear validating statements.  That said, this all places an imperative nature on the ability to see through the words and into the clinical evidence.  It’s no difference with Sepsis and its related conditions.  Especially in the light of the current pandemic, COVID-19 associated sepsis, septic shock and multiorgan dysfunction  have come to the forefront.

Join as we discuss coding and the clinical picture of sepsis so that you are armed for investigation and query when appropriate.

Attend this session to learn to:

• Utilize learned information to make logical decisions regarding coding and querying for sepsis;
• Apply rules for selecting the diagnosis and achieve medical necessity for reported services;
• Describe key ICD-10 guidelines and coding clinic guidance specific to coding for sepsis and apply this knowledge in their own provider’s claims.