Health Information Management

Tip: Have clear documentation when sepsis or SIRS is present on admission

APCs Weekly Monitor, April 3, 2009

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Never assume that sepsis is present on admission (POA). Sepsis or severe sepsis may be present on admission but the physician may not confirm the diagnosis until some time after admission. When physician documentation stating that sepsis or severe sepsis is POA is absent or unclear, coders should query the physician. Similarly, coders should never assume that the presence of systemic inflammatory response syndrome (SIRS) criteria on admission allows the coder to report ICD-9-CM code 038.x (septicemia) as the principal code without corroborating physician documentation that verifies sepsis was POA.

This is especially important from a compliance standpoint because RACs found more than $300 million in potential revenue their first year in existence.

Editor's note: This tip comes from the February 5 HCPro audio conference "Sepsis Documentation and Coding: Clinical Indications, ICD-9 Guidelines, and Queries for Clarity." To listen to the audio conference, visit the HCPro marketplace.The tip also appeared in the March 19 issue of the RAC Report.



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