Health Information Management

Q&A: Clarifying ’septic shock’

CDI Strategies, April 12, 2012

Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

Q:  If a physician documents “septic shock” should the CDI specialist query for sepsis to show that both sepsis and septic shock were present, or can you code both conditions from the documentation of septic shock?

A: Sometimes things are easy, sometimes not so much. Physicians use the word “septic shock” for more than infections. For example, they may use the term to describe burns without wounds “sepsis,” and they may use the term for hemorrhagic pancreatitis without abscess. If, indeed, the patient has shock (and the CDI specialist may want to make sure that “shock” really exists) and there is an infection going on that the physician relates to the shock, then the principal diagnosis would be 038.9 followed by the code for the septic shock and 995.92 for severe sepsis plus the code for the infection. 
 
If the physician is using the word “septic shock” for a noninfectious process, then the noninfectious process has to be sequenced first followed by the code for shock and 995.94.
 
Editor’s Note: This question was answered by Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta, following the March 29, audio conference “Sepsis Coding: Learn Documentation Improvement Techniques to Ensure Accurate Coding.”
 
For additional information, read:



Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

    Briefings on APCs

  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • Medical Records Briefing

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular