Q&A: Coding acute organ dysfunction

CDI Strategies - Volume 17, Issue 12

Q: I have a question regarding acute organ dysfunction. If a provider documents “hyperbilirubinemia related to severe sepsis with acute organ dysfunction,” will this suffice for coding acute organ dysfunction, or should I query for a more definite diagnosis? 

A: This is a great question. “Hyperbilirubinemia” is a lab value only, not unlike when a provider documents “transaminitis” (meaning elevated liver enzymes). The finding is abnormal, so you would want greater specificity as to the cause of the elevated bilirubin.

The provider has linked the hyperbilirubinemia to sepsis, which would indicate an acute issue. However, this cannot be assumed. An elevated bilirubin typically indicates liver dysfunction. Based on the clinical indicators in the medical record, you would query for the underlying issue. “Liver dysfunction due to sepsis” will code to other specified diseases of the liver, so you want to be more specific. Depending on the clinical indicators, the elevated bilirubin could be due to acute liver failure or hepatitis, whether inflammatory or infectious. The more specified diagnosis defines the acuity of the patient.

As you may know, sepsis is a highly audited and denied diagnosis. Linking an elevated bilirubin to sepsis is important, but a more specific diagnosis related to the abnormal lab value that is associated with the septic state better supports the diagnosis of sepsis for clinical validation.

Editor’s note: Kim Conner, BSN, CCDS, CCDS-O, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at kconner@hcpro.com

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