Health Information Management

Tip for coding sepsis

HIM-HIPAA Insider, June 5, 2012

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Coders should review documentation thoroughly, query when necessary, and consider the following tip when coding sepsis:  Note differences between streptococcal sepsis and streptococcal septicemia. When physicians document streptococcal septicemia, coders should report code 038.0 (streptococcal septicemia) only. They should not report code 995.9x (SIRS) as an additional code. Coders also should query physicians to determine whether a patient actually has sepsis instead, in accordance with official coding guidelines.

Nonetheless, query with caution, says Avery. "I think we over-query in this area for a condition that's really not there," she says. "I think a lot of physicians over time have become desensitized to it."
 
Coders should review clinical evidence in the record before querying physicians, she says. They should also be careful when referencing SIRS criteria to avoid backing physicians into a corner to provide diagnoses that may technically satisfy diagnostic criteria without actually being present, she says.
 
Conversely, if physicians document streptococcal sepsis, coders should report codes 038.0 and 995.91 (SIRS due to infectious process without acute organ dysfunction).
 
Note: This is one of seven sepsis coding tips from the June issue of Briefings on Coding Compliance Strategies.



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