Debbie- Please understand the difference between coding and abstraction. Our providers and support staff are also confused. We, the abstractors, have lengthy conversations explaining the difference. That's how it works in our system. The coders get the chart after pt is discharged and look for provider documentation. There are specific guidelines they need to follow. We have been told, the coders can not use criteria alone to code, rather noticing the criteria they need to inquire the provider to document severe sepsis or septic shock. If we (abstractors) see such inconsistency, we request chart to be reviewed again for recoding. The abstractors get the chart only after all coding and billing is completed. The abstractors review the chart for criteria being present, provider documentation, exclusions, etc based on the CMS Specs manual and the additional notes. So, from the abstraction point of view based on CMS specs manual, if severe sepsis is established with time '0' and initial lactate result is >=4, it would set the clock for septic shock (even if it is not coded as such!). We are striving for early recognition and timely treatment in our facilities targeting ED. Another thing to keep in mind is that any chart that is coded just as plain Sepsis (A41.9-Sepsis, unspecified organism) will be in abstraction bucket for review. If patient meets all criteria within 6hrs, it would be abstracted as such and subsequently will be assigned a pass/fail/excluded categories. Even though the chart might fails for septic shock element, it will not change the coding.
I hope this helps. Let me know if you have any questions. Marina Zhukov, RN, BSN Sepsis Data Abstractor Franciscan Administrative Center-Market 1149 Market Street, Tacoma, WA 98402 | MS 10-04 P. 253.552.5782 | I. 152-5782 [email protected]<mailto:[email protected]> www.CHIfranciscan.org<http://www.chifranciscan.org/> From: Sepsisgroups [mailto:[email protected]] On Behalf Of [email protected] Sent: Wednesday, February 01, 2017 6:14 AM To: [email protected] Subject: [Sepsis Groups] question CAUTION: This email is not from a CHI source. Only click links or open attachments you know are safe. ________________________________ 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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