Documentation best practices: Sepsis
Documentation of sepsis and linking it to the underlying infection and/or organ dysfunction accurately supports the intensity of your service, severity of illness, risk of mortality, length of stay and risk-adjustment metrics.
The following conditions may require a query for clarification:
“Sepsis syndrome”
“Sepsis syndrome” is considered nonspecific and is NOT synonymous for sepsis, i.e., “Sepsis syndrome d/t cellulitis” will only code to cellulitis.
Consider documenting “Sepsis d/t Cellulitis.”
“Urosepsis”
“Urosepsis” is considered nonspecific, there is no code for this diagnosis.
Consider documenting “Sepsis due to UTI” or “UTI without sepsis.”
“Sepsis in the setting of Left TKA”
“In the setting of” generally is interpreted as the two conditions exist at the same time, but does not demonstrate a cause-and-effect relationship.
Consider “Sepsis due to infected knee implant device.”
“Severe Sepsis”
To fully capture severe sepsis, an acute organ failure should be linked to sepsis, i.e. ‘Sepsis due to PNA with associated acute renal failure.”
Only use “Severe Sepsis” when there is an associated acute organ dysfunction.
Case examples
4 Day LOS: Medical case, impact w/o and with documentation of sepsis due to UTI with associated metabolic encephalopathy
7 Day LOS: Surgical case, documentation for L TKA revision with sepsis, without and with link to the knee implant device
