Journal excerpt: Things every coder wishes providers knew about sepsis documentation and coding
By Sarah Nehring, CCS, CCDS
From the coding and CDI perspective, sepsis can be one of the trickiest diagnoses. Here are a few things coders wish physicians knew about sepsis documentation and coding.
Urosepsis isn’t sepsis—not from a coding standpoint, at least. Unless you want a query, don’t document it. If it was a urinary tract infection (UTI), then document that. If it was sepsis due to a UTI, please say that in your documentation.
While we’re on the subject of UTIs, documentation of “sepsis due to UTI, patient with Foley” is going to prompt a query. Was the UTI due to the Foley? We can’t assume; we need you to tell us. This is true of any infections that may be related to a procedure or other medical care. Please remember that from our standpoint, coding a complication isn’t an assignment of blame or admission of fault. We have additional codes we can add to indicate if misadventure was involved, and we rarely need to. We do need you to document directly if you suspect that the infection was or may have been related to recent surgery or the presence of a device, and it’s important to indicate if that infection was likely present on admission.
Like urosepsis, bacteremia isn’t sepsis. Sometimes we see sepsis and bacteremia used interchangeably. From a coding standpoint, bacteremia is an abnormal lab finding—an R code, which means it falls into the Signs and Symptoms chapter of the codebook. It’s not ideal as a principal diagnosis on an inpatient admission.
As a secondary diagnosis, bacteremia is what we sometimes refer to as a “junk code”: It adds little value. We realize that sometimes the patient really did just have bacteremia, and in those cases, we’re stuck with it. However, if the patient met sepsis criteria, please avoid a query and let us code this as more than just an abnormal lab finding by documenting something like this: “Sepsis due to e-coli bacteremia.”