Q&A: Documenting sepsis and/or severe sepsis with septic shock

Q: Does sepsis and/or severe sepsis have to be documented in the medical record when only septic shock is noted? We have a couple of physicians that will document septic shock without noting sepsis and/or severe sepsis. I was informed that coding needs to also have the documentation of sepsis and severe sepsis along with the infectious source in the medical record.

For example, a patient with a perforated bowel, white blood count (WBC) of 15.4, heart rate (HR) of 120, and blood pressure (BP) of 89/50 was given multiple intravenous (IV) fluid bolus and IV Zosyn/IV Rocephin, then taken to surgery. At onset of surgery, the physician ordered neosynephrine started. The patient was then transferred to ICU, where the physician documented the diagnosis of hypotension and septic shock.

Moreover, I was informed that the patient may have had hypovolemic shock and not septic shock due since the physician documented that the abscess was ruled out, therefore no infectious source. My thoughts are that this patient met the diagnosis of septic shock with elevated WBCs, elevated HR, perforated bowel, hypotension, lactate acid of 3.5.

A: This is a great question and one that often confuses new CDI professionals. Let’s look at sepsis through the lens of the code set.

Sepsis is the body’s systemic reaction to an infectious process. So, in order for sepsis to be assigned, we need the presence of an underlying local infection. The sepsis would be sequenced first. In reading your scenario, the patient had a perforated bowel which likely means he had peritonitis. The physician would need to identify that local infection in his or her documentation. If there was no infectious source, you might consider systemic inflammatory response syndrome (SIRS) with shock. In reading your question, there is definitely an infectious source–you just might need to work to clarify it.

If the provider documents septic shock and it appears per your description that it is indeed supported with in the documentation, severe sepsis can be assumed. You cannot have septic shock without severe sepsis. When the provider documents septic shock, the provider is stating the patient has sepsis and that it led to shock. You would assign a code for sepsis, a code for the underlying infection and a code for the severe sepsis with septic shock. The following is an excerpt from the Official Guidelines for Coding and Reporting related to septic shock (Section 1, C,1-d):

2) Septic shock (a) Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction. For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Postprocedural septic shock. Any additional codes for the other acute organ dysfunctions should also be assigned. As noted in the sequencing instructions in the Tabular List, the code for septic shock cannot be assigned as a principal diagnosis.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, and CDI education specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.