Health Information Management

Q&A: Clarifying ’septic shock’

CDI Strategies, April 12, 2012

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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.”
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