Master the upcoming ICD-10 code and IPPS changes! Prepare your team for the upcoming changes taking effect on October 1. Discover the benefits of IPPSPalooza and how it can drive your success. Click here >

Retrospective Diagnoses: Discharging Sepsis Patients?

Dr. Ronald Hirsch recently had me read an article (Prevalence, Characteristics, and Outcomes of Emergency Department Discharge Among Patients with Sepsis) regarding discharging patients with sepsis from the emergency department (ED). Investigators identified subjects who had had cultures obtained and received antibiotics, presumably for an infection. The charts were then analyzed to see if Sequential Organ Failure Assessment (SOFA) criteria were met. If so, the authors concluded that the patient had sepsis. They then evaluated the patient’s disposition.

Their conclusion was that 16 percent of patients they had deemed as having sepsis were discharged from the ED, and those patients were more likely to be younger and less ill – and their localized infection was most likely to be a urinary tract infection (UTI).

I was happy to see that the study design used Sepsis-3 criteria, as opposed to Systemic Inflammatory Response Syndrome (SIRS), but the flaw in the study is that sepsis is a clinical diagnosis. Just having organ dysfunction concurrently with an infection does not de facto indicate sepsis. The provider must believe that the organ dysfunction is from sepsis. If a patient has acute kidney injury from dehydration or hypoxia, believed to be due to the localized infection of the lung (i.e., pneumonia), then the organ dysfunction is not considered to be sepsis-related and is thus not sepsis-defined.

Clinicians are best positioned to draw the conclusion of sepsis association at the time of the patient encounter. Retrospectively, it may not be clear what the etiology of the organ dysfunction is, unless the documentation specifies it. And if providers consistently produced that degree of documentation, I would be out of a job.

In my emergency medicine career, I am sure I missed cases of sepsis, but I am equally sure that I never knowingly or intentionally discharged a patient home with what I believed to be sepsis. Barring an unusually or unreasonably long ED stay, if the patient turned around promptly after a bolus of fluids and an initial dose of antibiotics and their organ dysfunction resolved, I would rescind my original impression of sepsis and downgrade that patient to a localized infection. In that case, I might send the patient home from the ED with continued antibiotics and close follow-up.

I used to think that even organic brain syndrome (OBS) was not an appropriate disposition for a patient who had true sepsis. I have since decided that in certain limited circumstances, a patient could be dispositioned to OBS with sepsis. The acceptable scenario would include a patient without underlying comorbidities, with reasonable hemodynamics, an uncomplicated source, and rapid resolution of what I was interpreting as sepsis-related organ dysfunction, like altered mental status or acute kidney injury (AKI).

This article illustrates why coders and clinical documentation integrity specialists (CDISs) are not allowed to presume a patient has a condition based on clinical criteria. They need the clinician to assert clinical significance. If there is an infiltrate on a chest X-ray, but no diagnosis of pneumonia…a query must be generated. Say that creatinine or troponin levels are elevated; is there a clinical diagnosis that corresponds?

Even another clinician, like the investigators of this study, or me, when I am performing a chart review, is not able to conclude sepsis after the fact. Being “Sick” with a capital “S” is inherent in the diagnosis of sepsis, and that takes clinical acumen leveraged in real time. Retrospectively, we may be able to intuit that there potentially was sepsis, but it would take inquiry of the treating physician to establish it as a definitive diagnosis.

If a CDIS questions the possibility of sepsis, an early query is advisable. It is not a coding and billing issue; it is for optimizing the patient’s medical care. Posthumous diagnosis of sepsis may get the patient in the correct DRG, but it is better to recognize and treat it aggressively, averting death.

Uncomplicated UTIs rarely meet medical necessity for admission. If there is organ dysfunction, that would be considered to be complicating the UTI. If treatment resolves the dysfunction, you are back to just a UTI. Discharge might be the appropriate disposition for a UTI, but not for true sepsis.

(If you read the original study, I also recommend you read the invited commentary, Elucidating the Spectrum of Disease Severity Encompassed by Sepsis, by Rhee and Klompas. It affirms my skepticism.)

Programming Note: Listen to Dr. Remer every Tuesday on Talk Ten Tuesdays when she cohosts the broadcast with Chuck Buck at 10 Eastern.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn
Email
Print

Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.

Print Friendly, PDF & Email
September 19, 2023
Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Explore comprehensive guidelines and best practices for secondary diagnosis coding in our illuminating webcast. Delve into the intricacies of accurately assigning secondary diagnosis codes to ensure precise medical documentation. Learn how to navigate complex scenarios and adhere to coding regulations while enhancing coding proficiency. Our expert-led webcast covers essential insights, including documentation requirements, sequencing strategies, and industry updates. Elevate your coding skills and stay current with the latest coding advancements so you can determine the correct DRG assignment to optimize reimbursement, support medical decision-making, and maintain compliance.

Print Friendly, PDF & Email
September 20, 2023
Principal Diagnosis Coding: Mastering Selection and Sequencing

Principal Diagnosis Coding: Mastering Selection and Sequencing

Enhance your inpatient coding precision and revenue with Principal Diagnosis Coding: Mastering Selection and Sequencing. Join our expert-led webcast to conquer the challenges of principal diagnosis selection and sequencing. We’ll decode the intricacies of ICD-10-CM guidelines, equipping you with a clear grasp of the rules and the official UHDDS principal diagnosis definition. Uncover the crucial role of coding conventions, master the sequencing of related conditions, and confidently tackle cases with equally valid principal diagnoses.

Print Friendly, PDF & Email
September 14, 2023
2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY24 Inpatient Prospective Payment System (IPPS) Final Rule, including new ICD-10-CM/PCS codes, plus insights, analysis and answers to questions from the country’s most respected subject matter experts.

Print Friendly, PDF & Email
2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

This third session in our 2024 IPPS Summit will feature a review of FY24 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from two acclaimed subject matter experts

Print Friendly, PDF & Email
August 17, 2023

Trending News