The coders cannot infer and give a diagnosis that is not in the pt's record. What they CAN do and WILL do is query the provider for this diagnosis based on the guidelines that they follow. If the provider then gives that diagnosis on the query, the pt will get coded as such.
You all probably know this , but - For the Core Measure, if a diagnosis is made post dc, which most of these queries are, we are not to abstract theses pt's. Same for if the only documentation of severe sepsis or septic shock is in the dc summary- we do not abstract. If you all did not know- coders guidelines are not the same as we follow per the SSC and the 3 and 6 hour time frames. These queries can be tricky and deceiving and we MUST be diligent in our education, communication and assistance to providers about queries. Also, in getting invalid queries overturned so that our own facility level data is accurate, as well as nationwide data that many decisions about sepsis can be based upon. Amy Crowley Sepsis Coordinator Medical City Denton 3535 South I-35E Denton, Texas 76210 P: 940-384-3254 C: 214-801-2950 DentonRegional.com This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing, or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email or contact the sender at the number listed. From: Sepsisgroups [mailto:[email protected]] On Behalf Of Gibbs, Katie Sent: Thursday, February 02, 2017 10:03 AM To: Chambless Deborah <[email protected]>; [email protected] Subject: [EXTERNAL] Re: [Sepsis Groups] question Correct, our coders do this. I believe they can also code septic shock if hypotension. From: Sepsisgroups [mailto:[email protected]] On Behalf Of [email protected]<mailto:[email protected]> Sent: Wednesday, February 01, 2017 9:14 AM To: [email protected]<mailto:[email protected]> Subject: [Sepsis Groups] question Hello group, I am being told by our quality department that if a patient is documented with severe sepsis and has a lactic acid greater than 4 that it is automatically coded as septic shock even though it's not documented. Is this true? Thanks, Debbie Chambless Sepsis Coordinator Osceola Regional Medical Center Kissimmee, Fl 34371 407-518-3949
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