I'm hoping somebody can help me solve a quandary with documentation and 
coding.

For patients with Severe Sepsis in whom an elevated lactate is the only 
organ dysfunction noted, are you able to use the 995.92 (severe sepsis 
code) at discharge?  We are being told by our coding team that the code 
995.92 requires simultaneous use of an organ dysfunction code, and that 
there is no such code for elevated lactate that would apply. In this 
instance, the coders would be required to query the physician.

Have others come across this as a problem?  How have you addressed it?

Thanks very much,

Joe
Joseph Clement RN, MS, CCNS
Clinical Nurse Specialist

San Francisco General Hospital
phone: (415) 206-6174
pager: (415) 327-0220
[email protected]
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