Coding Clinic prompts fresh sepsis education

The phrase “sepsis syndrome” is starting to appear in medical records these days, but unfortunately it’s a term that requires further clarification. When it’s used, CDI staff/coders should query the physician to clarify the condition being treated. That’s the latest guidance from AHA’s Coding Clinic for ICD-9-CM released in Second Quarter 2012 (pp. 21–22).

“Sepsis is something we all struggle with,” says Katy Good, RN, BSN, CCDS, CCS, AHIMA-Approved ICD-10-CM/ PCS Trainer and CDI program coordinator at Flagstaff (Ariz.) Medical Center. Physicians at Flagstaff understand the documentation requirements related to sepsis, she says. And her CDI staff doesn’t typically have to query for clarification, although it does sometimes need additional specificity to identify the underlying cause of the infection.