Health Information Management

Coding Sepsis Survey: You spoke, we listened

HIM-HIPAA Insider, June 24, 2013

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by Jaclyn Fitzgerald, Online editor

From difficulty distinguishing between documentation for sepsis, severe sepsis, urosepsis, systemic inflammatory response syndrome (SIRS), bacteremia, and septicemia to trouble with physician queries, coding for sepsis is often easier said than done. Two of HCPro’s expert speakers, Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer and Robert S. Gold, MD, created our “Coding Sepsis Survey” to analyze the challenges that surround coding for this medical condition. You shared your concerns with us, and we listened.Bryant and Dr. Gold are using your responses to draft the materials for the live 90-minute audio conference “Sepsis Coding: Clinical Updates and Communication Strategies” at 1 p.m. (Eastern), Thursday, July 25. 

More than 90% of the 707 survey respondents indicated that they experience ongoing “coding issues” surrounding the coding of sepsis. An overwhelming 88.4% of those respondents listed documentation as their major concern.  

The survey revealed that a major issue with documentation is physicians listing a diagnosis of sepsis without documenting the clinical indicators (64.5%). More than 60% of respondents noted that physicians often document the criteria for SIRS without writing out “sepsis.” Almost half of respondents (48.1%) were also concerned that clinical indicators often conflict with a diagnosis of sepsis. Nearly half of respondents (46.1%) said that they experienced situation where physicians identify SIRS in every case where two of the four criteria of SIRS are present and never link the criteria to an inflammatory cause.

Unfortunately, only 38.5% of respondents said that their CDI team and coding staff work together on documentation issues such as sepsis. When asked to comment on this, respondents often stated that they did not have a CDI team or that their coders were acting as CDI specialists.

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