Health Information Management

News: AHA's Coding Clinic offers clarification on 'sepsis syndrome'

CDI Strategies, September 27, 2012

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When the term ‘sepsis syndrome’ is documented coders and CDI specialists have to query the physician. That’s the latest guidance from Coding Clinic for ICD-9-CM released in its 2nd Quarter 2012 edition pp 21-22. The article states, “The term ‘sepsis syndrome’ is poorly defined. Query the physician to determine the specific condition(s) the patient has.”

Consider developing a tip sheet or poster to focus on the issue. Explain that the term ‘sepsis syndrome’ is not an adequate term to code sepsis, and let physicians know that you will have to query for clarification if that phrase is documented. Use the opportunity to add some additional language regarding guidance around documentation for Systemic Inflammatory Response Syndrome, septicemia, and septic shock.



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